Dr Aaron Motsoaledi, South African health minister: The fight against HIV/AIDS continues.

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0:30to make those markets work for you. Follow Merrin Talks Money on Apple Podcasts, Spotify, or wherever you listen. Hello, I'm Mayani Jones, the BBC's Africa correspondent, and this is the interview from the BBC World Service. The best conversations coming out of the BBC. People shaping our world from all over the world. If you're not a little bit afraid, then you're not paying attention. We have never seen a people so united. Do not make that boat crossing. Do not make that journey. Being born in America, feeling American, having people treat me like I'm not. We're more popular than populism. For this interview, I met Dr.

1:12Aaron Motualedi, South Africa's health minister in Pretoria. Dr. Motualedi has been at the centre of the country's public health response for more than a decade. A medical doctor by training, he first took on the health portfolio in 2009, overseeing the world's largest HIV treatment programme. A year ago, cuts to USAID, including USAID funding, sent shockwaves through the global HIV response community. This is a matter of life and death, the words of a major HIV charity. in response to Donald Trump's order to freeze US foreign aid for 90 days. Well, the decision has left refugee camps and emergency hospital clinics around the world in a real state of uncertainty.

1:57...ordered this 90-day halt to nearly all existing and new foreign aid, sending shockwaves across those organisations delivering humanitarian assistance, leaving a trail of chaos and confusion about whether people... I mean, one example is PEPFAR, which is a huge program that is administered by the State Department to try and suppress the HIV and AIDS transmission. I mean, I spoke to one former USAID official who said that they were literally contractors, clinics, you know, that are part signed up to this program, literally told they couldn't distribute the HIV medications and clinics were being shuttered.

2:37At a time, the head of UNAIDS, Winnie Biannima, warned of the consequences.

3:06reversed quickly. We urge for a reconsideration and an urgent restoration of life-saving services. Dr Motualedi responded by calling the cuts a wake-up call for Africa, arguing the continent would need to rely less on donors and take greater responsibility for its own health system. Now a year on, he reflects on what's changed, how South Africa is filling the funding gap and what the future looks like for HIV and AIDS treatment and research. It's also clear that global health cannot be tackled alone. When I called for universal health coverage, which we call NHI, it's a call for self-sufficiency, that local resources must be mobilised so that you don't depend on anybody.

3:51Of course, we won't do away with international solidarity, like organisations like the Global Fund, which has been established to fight HIV, HIV, TB and malaria. We can't claim that will be on our own, specifically because health is very much globally interconnected than many sectors. And pandemics do not know borders. I'm sure you are aware of that. So it's in the interest of the whole world to work together. So even though we say we want to be self-sufficient, but we don't think global solidarity must be dropped. because if it gets robbed, the world will be in trouble.

4:31Welcome to the interview from the BBC World Service, Dr Aaron Motwaledi. Well, we have got no option but to hit the wake-up call. That is why a few months later, the minister through Section 16 of the Public Finance Management Act provided emergency funding, a stop-gap measure, which coincidentally you interviewed me when only two days ago, parliament went to endorse what the minister's done in terms of the laws of the country. The parliament debated that special appropriation bill and they passed it and they believed it was necessary. But they also emphasized what I said, that this is a wake up call not to depend on anybody.

5:16And at any rate, you are aware that the U.S. has moved. There's no chance of them going back. They have adopted a new policy called America First Global Health Policy, where countries are supposed to sign with the U.S. to provide them with two very important issues, which I believe, frankly speaking, no nation on Earth that respect itself should accede to. That they will get their pathogen if there's any pandemic or epidemic in their area, if there's any outbreak. And they'll also provide them with a genome for life. But the US is going to give them money for five years. You are aware that the first country to sign was Kenya.

6:00The president signed, but parliament did not support that, none of that. And they went to court and the court reversed that. And that's a new deal. So there's no going back. That emergency funding that you mentioned that was implemented last year by the finance minister, right? What kind of was it meant to deal with? And has anything been put in place since then to ensure more long-term provisions in health? Well, it was emergency funding, which means the minister of finance is going to read the budget speed sometimes in February. He needs to make it permanent, no longer as emergency funding. Yes, that emergency funding was 750 million rand.

6:45Part of the money went to help research institutions via the South African Medical Research Council, and most of the money went to provinces to fill up the gaps. Like, for instance, one of the glaring weaknesses that we experienced was data capturers. People who captured data of who tested for HIV AIDS, who went to do viral loading and all that. And that became a very big weakness because most of the data capturers were the ones who were paid for from PEPFA. So provinces have hired their own data capturers to make sure that we're hitting the goal of self-sufficiency. Five provinces have already completed, only four are left, and they'll be completing before the end of this month.

7:30So the funding has gone towards things like data capture, for instance, and research and funding. Yes, I'm just giving an example of the issues that were very prominent, you know. But they also hired other staff members like lay counsellors, etc., etc. One of the country's leading research experts told us that in terms of HIV research, South Africa is now in a worse position now than it was when it was funded by the US. What do you say to that? Well, if a research institution was depending on the U.S. for their research, they would be worse off, obviously, if that research is withdrawn. So they might be right.

8:11But what happened is the Bill and Melinda Gates Foundation said they will help by contributing 100 million rands. And the Wellcome Trust also joined it. And they said they will do so to fund research in South Africa, provided for every$100 million they contribute. Treasury contributes$200 million. And our Treasury agreed. Agreed. So there's going to be$600 million provided for by$400 million from our Treasury and$200 million from the Bill and Melinda Gates Foundation and the Wellcome Trust. And the Treasury agreed. Part of this money that was appropriated two days ago is part of that research to make sure that research does not collapse in the country.

8:55The U.S.'s NIH, the National Institute of Health, says they will continue to help with existing research. But how will the government ensure you've talked about some money that you're going to match to the Bill and Melinda Gates Foundation and others? How will you ensure that new research projects can be started? Because South Africa is the leader when it comes to HIV research. Well, as I said, that money was given to South African Medical Research Council to distribute it among researchers and academic institutions which are doing research. We're not dictating to them what to do. We just said we'll try to give funding.

9:32And now you can imagine this funding, as I said, was a stopgap measure. We must find a way to continue funding our own research. But having said so, I need to add, the research that is happening in South Africa on HIV AIDS does not benefit South Africa. I'm sure you must know that it's going to benefit the whole world, especially the U.S. pharmaceutical companies. We are busy with research now for HIV vaccine, which we believe will be available in two years' time. You know, in its final stages of clinical research, it needed 20 ,000 people. 13 ,000 are provided by South Africa alone. And there are seven other countries globally which are providing people for that research.

10:20While the vaccine... People who are being tested, they're participating in the trial. Yes, yes. And our own researchers are also involved. While that vaccine becomes available, it's not available for South Africa. And in fact, the pharmaceutical companies that are going to manufacture it are likely to be American pharmaceutical companies. So it should not give an impression that when research is done here, it's done for South Africa, it's done for the whole world. The reason that it's done in South Africa specifically is because we have got material for that research, because we have got the highest HIV AIDS load in the country.

10:58We've got the highest TB load in the country, et cetera, et cetera. So what are you doing to convince stakeholders like the US or other people around the world that it's worth investing in this research in South Africa? Can any human being convince, Tam? You know, you are asking me to convince a lion to become a vegetarian. It's a very difficult job. There's a six-month bridge for Pep Farm until March to support some of the HIV work being done here. But it's not clear if it's going to be extended. What will you do if the US decides not to extend it? It won't be extended. I'm quite sure of that.

11:35But I don't think, fairly speaking, I may sound maybe ungrateful, but I don't think it will be desirable for it to be extended. I spent four hours with my staff. It's really a big mess. We want to integrate HIV AIDS project and move from vertical, you know, programs. Now, that money is available, but it's not fitting in with what the country is doing at the present moment. We try to plead, but it's not very clear how to use that. For instance, that money is not given to the state. It's given to NGOs directly, right up to the end of March. Now, we don't know what's going to happen after March. But what we do know is that if anything wrong happens, they don't continue.

12:21Those NGOs are going to rush to us. We are unable to prepare for the future because we actually don't know where in the dark nobody is telling us. So it is funding, it is help, but it's also problematic because it's not in fitting in with our programs. When a funder feeds, helps you, they must come and say, what do you need? Where? Where can we help? They can't come and say, look, I'll only do this for you and I can't do that. And I don't care about what you think and about your programs. It becomes very complicated. So then what do you do if this funding isn't meeting your needs right now? I know you said you'll match the contributions by the Bill and Melinda Gates Foundation.

13:03You said there's been money coming in from the Wellcome Trust. But long term, what can South Africa do to make sure that it funds the projects it needs in the way that it needs? Well, that's exactly the homework which we've given to Treasury. As I've told you, the Minister of Finance is going to read the budget now. It might not be immediately in this financial year because the budgeting process starts about eight months in advance, if I may put it that way. But going forward, the minister will have to make sure that we become self-sufficient. And that's exactly what Parliament was also emphasizing.

13:38By the way, this is also what I've been emphasizing when I called for universal health coverage, which we call NHI. is a call for self-sufficiency, that local resources must be mobilized so that you don't depend on anybody. Of course, we won't do away with international solidarity, like organizations like the Global Fund, which has been established to fight HIV, HIV, HIV and malaria. We can't claim that will be on our own, specifically because health is very much globally interconnected than many sectors. And pandemics do not know borders. I'm sure you are aware of that. So it's in the interest of the whole world to work together.

14:20So even though we say we want to be self-sufficient, but we don't think global solidarity must be dropped because if it gets dropped, the world will be in trouble. The treasury funding that you mentioned, am I right in thinking that it's only at the moment valid for one year? It's an emergency funding. Emergency funding cannot last for more than that. It was an emergency funding just for that period. and Parliament passed it as such. So what guarantees that you have that beyond that period of a year, there's still going to be funding there? No, no, no. That's why I'm saying it's the homework that Treasury needs to do.

14:52We presented that to the Minister of Finance during the budgetary process. We're waiting to hear from him. He is painfully aware and he even told Parliament that, yes, this was emergency funding just for now. And so he's painfully aware that going forward, something needs to be done.

15:13You're listening to the interview from the BBC World Service.

15:41work. And join me for a separate episode where I answer listener questions and how to make those markets work for you. Follow Merrin Talks Money on Apple Podcasts, Spotify or wherever you listen. I met Dr. Aaron Motswale-Lady at his offices at the National Department of Health in Pretoria. Talkative and affable, he was seldom defensive in his answers. I'd first spoken to him last year, just a few days after Donald Trump's swinging cuts to USAID funding. The announcement through South Africa's leading HIV research industry into disarray. It had been one of the main beneficiaries of funding from PEPFAR, the US President's Emergency Plan for AIDS Relief.

16:21Set up in 2003 by President George W. Bush, it's believed to be the largest commitment by any nation to address a single disease in history. Since its creation, the US has invested over$110 billion in the global HIV and AIDS response, saving 26 million lives. But following the abrupt end of that funding, Dr. Matsualedi told me in an interview at the time that his country needed to step up. A year on in our conversation, he was open about what still needed to be done. But he was also keen to talk about what he sees as success stories. One of them is Lena Kapovir, a drug which offers almost total protection from HIV, which is to be made available to low - and middle-income countries at a much cheaper price by 2027.

17:08Okay, let's return to my conversation with Dr. Aaron Motswaledi. When you were health minister previously under President Jacob Zuma, you kind of spearheaded the distribution of HIV, the purchase of HIV across South Africa. How do you feel about that situation now? No, it's going very strong. In fact, we are accelerating it because I have said and I'm still saying that South Africans must not accept and get used to the idea that we are going to live with a pandemic called HIV AIDS forever. We must think about bringing it to an end. And all our programs are moving towards that, to bring HIV AIDS to an end.

17:46And in this regard, we have launched three very, very important programs. The first one, which we launched on the 25th of February, is what we call 1.1 million clues that gap campaign. You might be well-versed with the UN AIDS formula. to end HIV, AIDS as a global health threat in what's called 95, 95, 95. I'm sure you know that. In South Africa, we are at 96, 79, and 94, meaning the weakness is the middle 95, whereby instead of 95 % of people who are positive being on ARVs, we only have 79. We calculated how many people will make us reach the 95. is 1.9 million people which we are looking for.

18:35And we launched that campaign called 1.1 million close the gap campaign. We've already found a substantial number of them bring them back to treatment. That's the first program. The second program is the Lena Kapova, which is coming. We are hoping to launch it and we are taking it so seriously as we want it to be launched by the president himself, not even by me. the Lena Kapava program to prevent HIV and AIDS. We've also launched, by the deputy president of the country, we launched Unwell TB Day on the 24th of March last year, a program to screen 5 million people for TB and put those who are found to be positive on TB.

19:18So we are actually running them simultaneously. So those are some of the things that we are really doing to bring an end. I know you said you're waiting on the president to launch the Lena Kapovir program? He's waiting for us. Oh, right. So when would you like to start rolling it out? He's waiting for us to give him a date. He's waiting for us. He's very enthusiastic. I've already spoken to him. No, no, we're still making... We want to launch it in the first quarter of the year. Yeah. Do you think there's enough of the medicine to be distributed across South Africa? Because an expert we spoke to doesn't think there's enough.

19:51For Lena Kapovir? Look, I'm sure you are aware that Lena Kapova, which is manufactured by an American company called Gilead, is very expensive, extremely so. But the Global Fund went to negotiate 2 million doses. And South Africa has been provided for 488 people. So we know how many people we can provide in the first year. We're not fooling ourselves. It's 488 people because it's a six-monthly dose. 1 ,000 or 400 and 800? 488 ,000. 1 ,000. Yes, which means you multiply the doses by two because we are going to give two doses, which means we have got more than 900 doses. Those will go for the whole year.

20:39We've already selected only 350 clinics where that will happen. And remember, we have got more than 3 ,000 clinics. So it's only 10 % of what we have. Then next question will be what happens going forward. During the United Nations General Assembly in the U.S., two very important things happened. The Clinton Health Access Initiative, headed by the former president of the U.S., Bill Clinton, came together with the VETS RHI, our own research institution here, together with an institution called Dr. Radice, whereby a generic is going to be manufactured by Dr. Radice Laboratories, which will now cost$40, no longer$28, which was original,$40 per dose.

21:30And that will only become available, I believe, next year. The second thing that happened is that the Bill and Melinda Gates Foundation did the same thing with another pharmaceutical company called Hetero, where they were given what you call voluntary licenses. I'm sure you are well-versed with the idea of voluntary license. Ordinarily, when a pharmaceutical company has done research and come up with a new product, under the global rules, they've got 20 years of intellectual property protection. That means for 20 years, they're the only ones who can manufacture that program. I mean, that product and sell it for whatever amount.

22:10But now, science has prevailed. voluntary licenses have been given, I think, to about seven pharmaceutical companies. So is your plan then to buy some of these generic versions of Lenacapavir and distribute them? Of course, of course. We are fighting HIV AIDS through generics. At the moment, the reason that we are able to put close to six million people on ARVs is because we are using generics manufactured mostly in India. With originator drugs, no country can afford that. Maybe the US itself. It's going to take at least a year for some of these generics to become available. So what happens? You said you've got enough doses for just over 400 ,000 people.

22:51Millions of people have HIV in the US, in South Africa. What happens to them? It's doses for 488 people. We're going to start with those. There's no program that started 100 % anywhere in the world. Even now, we are running the biggest HIV AIDS program in the whole world, where 6 million people are on ARVs. There was no chance of starting with 6 million. We started with one and went upwards. When I arrived in health in 2009, only 10 % of our facilities were providing ARVs. Now it's 100. So you always start bit by bit. And as I've already said to you, we have identified 350 clinics where we're going to start.

23:32That is the beginning because the Chinese said a journey of a thousand miles start with the first step. So we are taking the first steps.

24:14I've spent the last three decades trying to better understand money across the boardroom, the newsroom and the trading floor. That's longer than most podcast hosts have been alive. But even though I've got questions, join me, Merrin's Upset Web, every week for my show, Merrin Talks Money from Bloomberg Podcasts, where I have in-depth conversations with fund managers, strategists and experts about how markets really work. And join me for a separate episode where I answer listener questions and how to make those markets work for you. Follow Merrin Talks Money on Apple Podcasts, Spotify, or wherever you listen.