“Innovation without access creates injustice”

As UNAIDS’ new global report, United to End AIDS, warns that progress against HIV remains fragile, AIDS 2026 opens in Rio de Janeiro at a critical moment for the global HIV response. Shrinking funding, weakened prevention and community-led services, and the risk of the epidemic rebounding mean that the challenge is no longer simply to develop new solutions, but to ensure that they rapidly reach the populations who need them most. Philippe Duneton, Executive Director of Unitaid, discusses the conditions required to achieve equitable access to innovation: anticipation, community engagement, appropriate delivery models and regional manufacturing.

What conditions must be met for an HIV innovation to rapidly benefit people in low- and middle-income countries?

Philippe Duneton: First, we must remember that innovation does not simply fall from the sky. It comes from industry, but also from public and private academic research. Unitaid works with all these actors, including ANRS MIE, Institut Pasteur and many other international partners.

Brazil’s Minister of Health, Alexandre Padilha, used a phrase that I often repeat: innovation without access creates injustice. When solutions exist in one part of the world, generally in the wealthiest countries, while people facing the same needs elsewhere cannot access them, that is an injustice.

Access to prevention and care is a fundamental human right. Access to innovation must be understood within that framework.

Unitaid’s role is therefore to anticipate. We should not wait until a product reaches the market before beginning to negotiate its price or think about how it will be used. We monitor the innovation pipeline several years ahead and engage very early with researchers, pharmaceutical companies, generic manufacturers, countries and civil society.

I sometimes use the image of the film Minority Report. The idea is to act before the “crime” is committed. In this case, the “crime” would be allowing an innovation to exist without ensuring access to it. We therefore need to prepare licences, manufacturing, pricing, regulatory procedures and implementation conditions well in advance.

We obviously do not do this alone. We work with countries, the Global Fund, communities and partners such as Expertise France. Our role is to take a promising idea and help turn it into a solution that works in practice.

This anticipation can considerably reduce delays. For some antiretroviral medicines, more than ten years passed between their availability in the United States and their introduction in Africa. With lenacapavir, we are talking about a matter of months. That is still too long, but this acceleration has been possible because the work began long before the product became available.

Lenacapavir is regarded as a major advance in HIV prevention. What does it teach us about the need to anticipate access?

Philippe Duneton: Our work on lenacapavir did not begin a few months ago. It is part of more than fifteen years of investment in pre-exposure prophylaxis, or PrEP, and in identifying solutions adapted to the needs of different populations.

One of the key challenges was to develop a prevention tool that was genuinely effective for girls and women. Oral PrEP has delivered important results, particularly among men who have sex with men. However, among some other populations, including young women, daily oral prevention has not always proved well suited to real-life circumstances and adherence challenges.

Lenacapavir fundamentally changes the outlook. Two injections a year can offer very high levels of protection against HIV. As soon as the clinical data became available, we began working with Gilead and generic manufacturers to prepare for access.

An agreement has made it possible to announce a target price of USD 40 per person per year for generic versions covered by the agreement. The aim is to achieve a price level comparable to that of antiretroviral treatment. The arrival of the first generics within a very short timeframe would represent an exceptional acceleration compared with previous innovations.

But a great deal of work is still required. We need to make sure that manufacturers have sufficient production capacity, that products meet quality requirements, that they are prequalified by the World Health Organization, registered in countries and incorporated into national guidelines.

We also need to secure volumes and supply. We cannot initiate someone on a prevention option unless we can guarantee continued access to subsequent doses. This is an essential condition for trust.

Unitaid is supporting the initial introduction of lenacapavir in South Africa, Zambia and Brazil. What do we need to learn now about the conditions for its use in real-world settings?

Philippe Duneton: A clinical trial can demonstrate that a product works. Using it under real-world conditions is another matter.

We need to understand how to reach and support the people who could benefit, provide appropriate counselling, ensure confidentiality, make it easier for people to return for their next injection and identify the most appropriate service delivery settings.

The same models will not necessarily work in South Africa, Zambia, Brazil or in countries where the epidemic is more concentrated among certain key populations. Needs depend on epidemiology and health systems, but also on social and cultural realities.

This work must be led in countries by national and local actors. It cannot be decided from Paris or Geneva. This is also the approach underpinning our cooperation with Expertise France, particularly on cervical cancer prevention and treatment: strengthening national institutions and implementing partners so that they can build their own expertise, document it and share it.

The aim is for them to be able to support scale-up themselves, both within their own countries and in other countries facing similar challenges. Countries should not simply be places where solutions are deployed; they should generate expertise and share it with others.

Initial feedback on lenacapavir is encouraging. Its administration twice a year can remove very practical barriers. For some young women, keeping tablets with them or at home may expose their private lives, raise questions or make prevention difficult.

A twice-yearly injection therefore does more than improve biomedical effectiveness. It can also change the practical conditions in which people access prevention.

Different delivery models are currently being tested, including through health centres and pharmacies. Discretion, anonymity and proximity may be decisive. However, these models will need to be monitored over time and adapted as implementation expands.

Civil society also plays a critical role. Information materials and communication tools cannot simply be produced by technical experts. They must be designed with the people concerned and be meaningful and relevant to them.

People will always end up telling you what works for them, what they need and what prevents them from accessing services. We have to listen to them.

You also advocate for a more integrated approach to health, particularly for women. Why?

Philippe Duneton: Vertical programmes have delivered considerable results. But people do not experience their health one disease at a time.

When a young woman accesses an HIV prevention service, she may also need contraception, testing and treatment for sexually transmitted infections, hepatitis prevention, care during pregnancy or cervical cancer screening.

We therefore try to start from the person rather than from the product. The right question is not only: how do we provide lenacapavir? It is also: what services does a young woman need at different stages of her life?

We cannot ask people to come one day for HIV, another for contraception, another for cervical cancer and yet another for a different condition. Health systems need to be better organised around people’s needs.

This integration does not mean abandoning key populations. On the contrary, it requires us to design responses that reflect different epidemiological and social realities, while maintaining targeted services whenever they are necessary.

At a time of major contraction in international funding, can existing services be protected while access to innovation is accelerated?

Philippe Duneton: The situation varies considerably from one country to another. There is no single African reality. Some countries have greater financial resources, stronger institutional capacity and stronger health workforces. Others are far more vulnerable to interruptions in international funding.

The abrupt cuts to US global health assistance caused major disruption. In some countries, testing and prevention services were left without staff overnight.

Treatment services have often been protected as a priority, particularly thanks to the commitment of communities and civil society, sometimes with extremely limited resources. In several countries, they managed to maintain essential services despite having very few resources. They did not simply compensate for disruption; they also showed that they could organise effective responses that were close to communities and adapted to local realities.

This crisis nevertheless reminds us that progress remains fragile. In public health, we know the rebound effects that can occur when services are interrupted.

Does this mean we should give up on innovation? I do not believe so. I have never seen a major public health problem solved without innovation. I have tried practising medicine with my bare hands: it does not work.

What shocks me is that the poorest people too often pay too much for poor-quality services and substandard medicines. That is what I am fighting to change. They must be able to access quality services and products, including when they have to pay out of pocket.

Innovation is not simply the arrival of an expensive new product. It can be a paediatric medicine that is easier to administer, a treatment reduced to one tablet a day, a test that withstands high temperatures or a community-based model that reaches people who do not attend health facilities.

When we began working on HIV, some patients had to take more than twenty capsules a day. They sometimes removed them from their packaging so that they could hide them at home. But once the tablets were mixed together, it became difficult to know which ones to take and when.

Moving to one tablet a day profoundly transformed adherence and people’s lives. That is also what innovation means: having the right tool, at the right price, under conditions adapted to people’s reality.

We therefore need to protect essential services while investing in tools that can make them simpler, more effective and less costly. Countries with the capacity to do so will need to mobilise more domestic funding. But international assistance will remain essential for countries and populations that have no other option.

Access to innovation must remain a core function of global health. The debate cannot focus solely on reorganising institutions. The real question is what we are trying to achieve and which functions must be protected in order to get there.

Market forces cannot be allowed to determine access on their own; people’s needs must come first.

What role can regional manufacturing play in this new approach to access?

Philippe Duneton: Since the Covid-19 pandemic, regional manufacturing has become an integral part of our vision of access.

It is not reasonable for an entire continent to remain almost entirely dependent on external sources for medicines, diagnostics or vaccines. This is a matter of security of supply, resilience and health sovereignty.

Unitaid has invested around USD 100 million in initiatives supporting regional manufacturing. We support the production of medical oxygen, antiretrovirals and antimalarial medicines. We are also working with the South African authorities as they engage with Gilead to make the future production of lenacapavir in South Africa possible.

However, we need to talk about regional manufacturing and avoid suggesting that every country can manufacture every product it needs on its own. A manufacturing facility can only be sustainable if it understands its market, its competitors and the demand it is seeking to meet.

Quality must never be compromised. That is why strengthening regulatory capacity is essential, including through the African Medicines Agency and cooperation between national and regional regulatory bodies.

African manufacturers are capable of producing quality products at competitive prices. Some are already working on decarbonising their production processes and controlling energy costs, which they see as a genuine strategic advantage.

Regional manufacturing is therefore not a political or symbolic add-on. It must be fully integrated into access strategies, together with all the necessary regulatory, industrial, economic and environmental dimensions.

In this context, what message do you want to bring to AIDS 2026, and in what state of mind are you approaching the conference?

Philippe Duneton: I would describe myself not so much as optimistic, but as determined to keep fighting.

My work as a doctor, and later as Unitaid’s Executive Director, has always led me to focus on what is not working: someone who falls ill and does not know where to get tested, or a mother watching her child become sick without being able to access a solution.

But we also have evidence that changes once considered impossible can become reality. At Unitaid, we have seen innovations and access models succeed because we took seriously the question of how they would be implemented in practice.

True innovation often begins when everyone says that an idea will never work.

AIDS 2026 should bring together those who have already helped transform the HIV response and allow us to say to them: this is a difficult period, but together we can still invent solutions that we cannot yet imagine today.

We need to move faster, work differently and never lose sight of people. Innovation must exist for them.