The international response to HIV during the 1990s and 2000s marked a milestone in what we now recognize as global health nowadays. Initiatives such as the U.S. government’s PEPFAR program, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, or UNAIDS were created during this period. Alongside these, the growing role of philanthropic organizations and, of course, the global mobilization of civil society brought significant changes to the governance of global health. The mobilization of Civil Society Organizations improved access to medications, promoted transparency and increased the representation of civil society in international governance. It also helped establish the access norm—an informal normrecognizing access to essential medicines as a fundamental component of the human right to health.
This norm turned into significant wins for the access to medicines movement, such as the Doha Declaration, which prioritizes public health over intellectual property rights; the inclusion of the first antiretrovirals on the WHO’s list of essential medicines; or the creation of organizations like Unitaid and the Medicines Patent Pool, which have helped improve global access to medicines.
Historian Charles Rosenberg says that “disease necessarily reflects and lays bare every aspect of the culture in which it occurs.” In the 1990s and 2000s, there were great inequities to access HIV treatments, with devastating consequences for those most affected by the pandemic. However, this era also saw the crystallization of the access norm and the inclusion of international collaboration in many countries’ foreign policies as a means to achieve the human right to health.
Despite these advances, inequality in access remains. According to UNAIDS, between 7.4 and 10.8 million people living with HIV were still not receiving treatment in 2023, half of them in Sub-Saharan Africa. Only 3.5 million people had access to pre-exposure prophylaxis (PrEP), far short of the target of 10 million by 2025. As in the 1990s and 2000s, access to innovative medicines that could facilitate the control and prevention of HIV is hindered by unaffordable prices and monopoly barriers.
For instance, the development and commercialization of lenacapavir—a new drug enabling HIV treatment and prevention with just two annual injections—could bring the UN’s 2025 targets within global reach. However, its high price (around €40,000 per person per year) will impede vulnerable populations and people living with HIV worldwide from accessing this new therapeutic tool.
As in the past, civil society mobilization has pushed Gilead, the company commercializing this drug, to sign a voluntary licensing agreement. Yet, this agreement remains insufficient to guarantee equitable access. However, unlike in earlier decades, the global health policy context is now shifting rapidly. Geopolitical tensions are influencing international health negotiations, anti-human rights rhetoric is gaining traction, and the failure to respond equitably to the COVID-19 pandemic has spurred a wave of policies focused on health sovereignty, regional autonomy, and nation-centered approaches to future health emergencies.
Global Health in a changing political context
World AIDS Day should remind us that global challenges like the AIDS pandemic can only be addressed when national policies align with the international agenda to uphold human rights. At Salud por Derecho, we work to ensure that policies developed in Spain, Europe, and international forums promote the right to health coherently.
For example, we have criticized Europe’s migration policies, which directly harm the health of migrant populations before, during, and after migration. According to UNAIDS, structural discrimination against migrants—including healthcare exclusion, stigmatization, and racism—leads to greater vulnerability, exposing migrant populations to higher risks of acquiring HIV in destination countries.
In pharmaceutical policy, we have participated in the public consultation on reforming Spain’s Royal Decree-Law on Health Technology Assessment to ensure transparency in the development and production costs of medicines, such as lenacapavir or cabotegravir. Transparency is crucial to achieving more affordable and fair pricing in Spain and elsewhere, as many low- and middle-income countries use Spain’s public (non-secret) prices as reference points.
We have also highlighted how the current revision of European pharmaceutical legislation presents an opportunity to align Europe’s innovation model with improved health and access to medicines, including HIV drugs. In this regard, we have criticized the position of the majority of countries to extend monopolies on innovative products, as this would further inflate the prices of medicines like lenacapavir.
New HIV therapies such as lenacapavir demonstrate the potential of pharmaceutical innovation, but also how public policies—pharmaceutical and non-pharmaceutical, national, regional, and international—serve as determinants of global health, often perpetuating health inequity worldwide. For this reason, civil society’s work and mobilization remain essential to mitigating the negative effects of policies on people living with HIV and those at risk of acquiring it globally. The guiding principle remains that the best national health security policy is the defense of the human right to health for all.
