Elie Hassenfeld: [00:00:00] Hey everyone, I'm Elie Hassenfeld, GiveWell's co-founder and CEO. In the conversations we've been having recently, we've been talking about GiveWell's response to US government cuts in foreign aid, some of how we've thought about urgent needs, some specific grants that we've made.

Today, we wanna look more towards the future and focus on an area that we could imagine starting to provide additional funding to because of the cuts. That area is HIV/AIDS. This is an area that GiveWell has not looked into very much in the past, and that's primarily because the US government gave a lot of funding to support it.

Historically, the US has provided around $5 to $6 billion of funding annually for HIV programming in low- and middle-income countries. In many Sub-Saharan African countries, countries like Nigeria or Malawi, HIV programs were largely donor funded. [00:01:00] Often a majority of funding came from the US government. And now, we think it's possible that there could be cuts of anywhere from 20% to 50% of US government funding for HIV. And so this means there really could be much greater needs in the area of HIV/AIDS than there were in the past.

And I think this area that we're talking about is a good illustration of how GiveWell works. So, GiveWell's really about trying to find the programs where additional funding will do the most. And even though HIV/AIDS is not an area that GiveWell has looked at in the past, because of these funding cuts, it's an area that we want to learn a lot about, because we think there may be really cost-effective funding needs in HIV/AIDS into the future.

It's also an area that is very new to us, there's a lot we don't know, but I thought it would be interesting to talk through what we've done so far. So joining me today is Alice Redfern. She's a program officer on our research team. She's done some of the work trying to get our understanding of HIV/AIDS up to speed.

So Alice, thanks for [00:02:00] joining me today.

Alice Redfern: Hi Elie. Thanks for having me.

Elie Hassenfeld: Before we dig in, can you just share a bit about yourself, your background?

Alice Redfern: Sure, yeah. So, I'm actually a medical doctor by background, so I did my undergrad and grad both at Oxford University. My undergrad was weirdly focused in neuroscience, and then we got into the clinical science after that, but the whole way along I was dabbling, I guess you could say, in public health and development. I did some work sort of in HIV/AIDS with a professor in Oxford in South Africa for a while, and then ended up working at IDinsight in Kenya for several years and then in the Philippines for several years.

And I just moved to GiveWell at the beginning of this year.

Elie Hassenfeld: We're grateful that you came over and you're here. Let's dive in on HIV/AIDS.

So, You know, HIV/AIDS is a very big area of programming. There's focuses on treatment, testing, prevention. I'm curious from your perspective right now, like which of those areas do you think are most likely to receive GiveWell funding in the future?

Alice Redfern: Yeah, sure. So HIV/AIDS as an area is extremely [00:03:00] broad. You've covered the main buckets, treatment, case finding, prevention, but within that, you could take just prevention and there's hundreds of different models of programming and so many different ways you could go about it. And I think plausibly within any of those buckets, there might be programs that look really cost-effective to GiveWell. And that's part of what makes it really interesting to look into at the moment.

Where we stand right now is a lot of response to the gaps and what's going on in the sector at the moment. You mentioned just the scale of funding that was coming from the US government prior to this and where we are seeing those funding gaps being really focused on is in the prevention space. Broadly speaking, a lot of the funding going towards treatment is being maintained, at least for now. Even prevention drugs for preventing the transmission of HIV from mother to children is being preserved. But prevention for really high risk populations is starting to see some very real gaps, and there have been a lot of program cancellations already, a lot of programs shut down in a lot of different [00:04:00] places. That's one area that we're definitely interested in looking into more.

I think another area that's liable to lose attention in the space of everything else going on is the support of scale up for new innovations. There's a really strong pipeline right now of new innovations around prevention, things like Lenacapavir, which is a longer acting drug for prevention. At a point where there's a lot of scope for funding to be withdrawn on a lot of things, I think it's pretty risky if something like that gets abandoned.

And I also think that we could end up moving money in spaces around treatment, around any of these things if gaps started to appear in places that looked interesting to us.

Elie Hassenfeld: In thinking about like which areas might receive GiveWell funding, it really depends heavily on what ends up happening with US government funding to HIV and that's something that I guess there've been a lot of different signals about, but we still just have huge uncertainty about what the future might bring, and that will end up influencing a lot of what we end up doing in the future.

Alice Redfern: Yeah, that's exactly right. I think it's hard to understate how much of a [00:05:00] big player PEPFAR has been in this space and still is. So we're really looking for those opportunities at the margin beyond what those larger funders are already covering.

And one area that we are reasonably certain right now is going to need more attention is this high risk prevention space that appears to already have lost a lot of attention and funding.

Elie Hassenfeld: Let's talk about that a little bit. So basically, we're trying to figure out some of the areas GiveWell funding might go to in the future. Obviously like getting there will be a lot of work. We don't know what the government will end up funding, what it won't.

There are the treatment programs, so this is when people have HIV and they receive antiretroviral therapy and they stay on that treatment to just slow the progression to disease.

Our best guess is that will be retained. Also, giving pregnant mothers treatment to prevent transmission to their unborn children or children who are nursing. So our best guess is that will be maintained.

But then in talking about prevention as an area that could need more funding, and then you're focusing on high risk groups. So could you say more about what you mean by high [00:06:00] risk groups? What kinds of programs are those that you could imagine us supporting in that area?

Alice Redfern: Sure, yeah. So there's a lot of programs that fall into that gap, but really what we're talking about here is, targeting key populations who are at higher risk of contracting HIV, and then also, if they were to catch HIV, of spreading it onto others.

In a lot of places, that means we're talking about vulnerable groups like men who have sex with men, drug users, sex workers, migrants. But the thing that makes it a bit more complicated is that in Sub-Saharan Africa, the population that has one of the highest risk is adolescent girls and young women, which covers a huge population.

So from a GiveWell perspective, you know, we're looking for where our money can go the furthest in terms of impact. For that you really need to find those populations where there's this very high rate of transmission, where if you are going to try and find them and then give them a pre-exposure medicine to reduce their risk, that's where I think we could have the biggest impact on overall transmission rates.

Elie Hassenfeld: So the program you're describing [00:07:00] here is giving medication to people who are at high risk of contracting and then transmitting HIV. What are the details of that program, like how does it work?

Alice Redfern: Yeah, so it looks different in a lot of different places, and it depends on the population that they're trying to target. And unfortunately, a chunk of these have already been shut down, this year as a result of funding shifts. So in a lot of places there might be outreach community health workers who are going out to try and directly find these patients, advocate for them, and follow them through if they end up being on treatment, and make sure they still have access to treatment the whole way through.

In some places, they have specialty clinics that are set up for these populations to drop in. And in those clinics, people are trained to deal with the kind of stigma and issues that these populations are dealing with. There's a lot of civil society organizations that work in this space as well. It's a lot about trying to find this population and funnel them into delivery modalities that already exist. In some countries that's more integrated in the healthcare system, but in a lot of countries it's still relatively separate.

Elie Hassenfeld: So [00:08:00] you described high risk populations, and one set of groups seems to me like a smaller slice of the population. Men who have sex with men, sex workers, migrants, and then another was this very broad group, adolescent girls. In this conversation here, are you thinking about both of those groups, or is there some distinction? I guess like another way of putting this question is if you had to guess, would you guess that there will be, higher burden of disease and higher cost effectiveness in one group versus the other? Or you really don't know, and it will just depend on what we find?

Alice Redfern: I think it just varies from country to country, that's what's made thinking about this particularly challenging is we are very new to this space, and I think we have an idea about a type of program that has really high transmission rate, is very effective at finding these people, and then giving them prevention medicine. But there's so many programs out there, a lot of noise going on and trying to find those ones that look uniquely good is quite challenging.

There's probably people listening who are like, I think my program looks like that. And it's, it is very possible, and we are trying to have a lot of those conversations right now. Some of the conversations we've been having are [00:09:00] around should we focus down first to one country where we think we're more likely to find a program and populations like this just to make it easier for us to think about the problem. It's tough to tackle when you're relatively new to the space, we've been leaning a lot on our partners to learn about it.

Elie Hassenfeld: The central challenge here is that to support the most cost effective programs you have to find the locations where someone is operating a program that is efficiently reaching a high risk population, which is some combination of their activities and also like the underlying rate of HIV/AIDS in that population.

And I guess there's no straightforward mechanism for identifying those locations in aggregate. It's just like a hard search problem, say like, well, how do we go about finding the community health worker program that's good at identifying the patients or the specialty clinics that are particularly efficient, but also, are the places where high risk populations are coming to them in high burden areas.[00:10:00]

Alice Redfern: Yeah, exactly that. I think that's the first summary of the problem. It's a big searching problem, and it's just really tough when it is new partners that we've not worked with as much before, it is a completely new space. We're dealing with a lot of countries and a very huge scale of problem to try and dial in on what's gonna look good for us.

Elie Hassenfeld: What do you think makes this different from other programs GiveWell recommends. In say like seasonal malaria chemoprevention, this malaria preventative program, we're looking at a high level at the burden of malaria in a large geographic region. But Malaria Consortium is delivering medication to all children under five in those areas.

What makes this different structurally? Like why would you expect this to have more of a search problem that's different from, say, the seasonal malaria chemoprevention program that's so much wider distribution?

Alice Redfern: I think that the problem is, I might be wrong on it, but my understanding as it is right now is that the general approach is just not going to look very cost effective to GiveWell, because of the scale of the [00:11:00] population, the cost of reaching such a huge population, and that the average burden across that population and average risk level is not as high.

So the way for us to see a program that's gonna look at or above our bar is to drill down to those like really very good programs. I have no doubt that they're out there. I think that there's many of them out there, but we're working across a very large scale to try and find them.

Elie Hassenfeld: It's like what we're trying to do, I mean, this is gonna be overly simplified, but you could avert an unnecessary death in malaria or avert an unnecessary death in HIV/AIDS, where we wanna avert as many unnecessary deaths as possible with the funding that we have. In HIV/AIDS, if you were to try to provide preventative medication to everyone, it would just not be very competitive with funding we can provide in other areas.

So in order to do that in HIV/AIDS, you're really looking for the populations that are most likely to contract and then transmit HIV and that is like a smaller subset of the population than it is in something like malaria where, I don't know if this is [00:12:00] exactly right, but you really know which population is most at risk. It's this small slice of the demographic, which is just children of a certain age.

Alice Redfern: Yeah, it's exactly that. And I think with malaria also, it's a kind of geographic population. It's not specific people within the population that carry that risk. The other thing I would say is, I think that's a very good summary of where we are, and it's just a kind of GiveWell size problem. I think other funders don't face this in the same way because they're just looking at HIV as a whole and so from that approach and from that lens, you would make some different decisions about how you go about this, but from GiveWell's side of making each individual dollar go the furthest it starts to look a bit different.

Elie Hassenfeld: Can we also then just talk for a minute about how this program works? It's giving preventative medication to people who could contract HIV, but just walk me through like, what's the medication? How often do you take it? How long do you have to take it, how much does it cost? You know, just to get like a basic sense of the figures.

Alice Redfern: Yeah, sure. So the medication is a oral pre-exposure prophylaxis. It's structurally pretty [00:13:00] similar to the drugs that we give to treat HIV, it's just different formulations. And there's a lot of different ways that you can go about delivering it. But I think the one way that most people are leaning towards is this risk informed approach, which would be that you find these people that are high risk, you make sure that they're aware of their risk and, if they feel like they're in a time of their lives where they're at particularly high risk of contracting HIV, they would then take the pill every day throughout that time.

So it's taking a medication every single day. And that's why it's, in a lot of ways, really great that there's some other innovations that are coming up down the line because a big challenge with PrEP has always been getting people educated enough to take it and to keep them adhering to it. It's tough to ask someone to do that.

Elie Hassenfeld: Presumably they come into the clinic regularly to pick up?

Alice Redfern: Yeah, and they have to do a quick test every now and again, I want to say every three to six months to keep accessing it, to make sure they've not become HIV positive during that time. So, there's a relatively high burden on the individual [00:14:00] to keep it up.

Elie Hassenfeld: Yeah, and so what is roughly like the cost per person, per year of it?

Alice Redfern: You know, different people take it for a different amount of time. I was trying to get to this answer of how much does it cost per person per year, and a lot of the times people will just say, it depends because one person might take it for a month, one person might take it full time for six months.

Elie Hassenfeld: I guess someone could take it for a month because they would just choose to stop. But you would generally expect that people who are at high risk at some period of their lives will be at high risk for some period that's longer than just a month.

Alice Redfern: Yeah, I think this is when you get into a lot of the behavioral aspects, and it gets really complicated really quickly for the individuals on the ground. You might have a woman who's in a relationship that's very challenging and she feels like it's gonna be helpful for her to take for a while. You might have someone who has not been using drugs and they feel like they might go and start using drugs again. So it just looks very different on the individual basis.

Elie Hassenfeld: Got it. Okay. So there's this program where you can come in, take preventative [00:15:00] medication, you have to take it every day, so that has this huge behavioral issue. And then, you mentioned new innovations that make this better. So there's an injectable called Lenacapavir, which has a similar effect. Talk a little bit more about how that works and what that could mean for HIV prevention.

Alice Redfern: I'll just start by saying that people have been trying to improve the options in prevention for a really long time. I think that everyone in the space will acknowledge that oral PrEP by itself is not the answer to preventing HIV. So people have been innovating on this for decades.

There's already one long acting injection called CAB-LA on the market, or coming onto the market. Lenacapavir is a bit different. The trial results that have just come out in the last six or so months are extremely encouraging. It had a hundred percent efficiency of preventing infections in a very large trial of adolescent women and girls, including a sample from Sub-Saharan Africa. And in another trial it was 96% effective at preventing infection. That's just at a level that you know, you rarely even see that from a vaccine.

Elie Hassenfeld: How [00:16:00] many injections over what time period?

Alice Redfern: The injection lasts for six months. At the onset, they have to take an oral medication one day. And then the next day I think they come in for another oral medication and the injection, might be getting the details of it off, but that's roughly it. And then six months later, they would just need another injection as a topup. And it has, you can imagine a ton of advantages for that. There's no requirement for adherence anymore, there's no requirement for you know, women who want to hide that they're taking medication from someone, it's just done. And the fact that it's got such a high rate, I think there's even some talk about whether it could only be given once every 12 months. I think we're quite a long way from that.

There's been years worth of work trying to develop an HIV vaccine, there's been some progress, but it still looks very challenging. This, I've heard people talk about it as a game changer in the space, as close to a vaccine as we're going to get.

So pretty exciting that's in the pipeline, but then obviously this has all emerged at the same time as the whole landscape is shifting, and that's pretty nerve wracking for people who work in the space.

Elie Hassenfeld: What would you say [00:17:00] are our next steps with assessing something like Lenacapavir? Like what are the questions that we're going to be trying to answer over the next 6 to 12 months to be making a decision about whether or not it's a place that you know, we would direct funding?

Alice Redfern: So the things that we're looking out for are, what's the kind of appetite for this across the different countries that is being taken to? Do we think it's feasible and realistic that it's going to be delivered at a cost that would make this look cost effective? And I say there's a lot of people working in the space that are trying to get it there, but it's a very long way to go to get there.

Elie Hassenfeld: Even if it's an extremely effective prevention tool, if it's too expensive, it may not, end up working.

Alice Redfern: Exactly. And in the context where you have country governments who are having their support from donors reduced and who are having to make really tough decisions about where to spend the money that they do have, are they going to spend that on an expensive injection, or are they going to spend it on maintaining treatment for people who they already know are infected?

I think that they will probably [00:18:00] spend it on treatment, and I think that's probably the right answer, but, this could be something that could really change the direction of the epidemic in the medium to long term. So it's some tough trade offs there that everyone is having to make right now.

Elie Hassenfeld: Right. It seems like there's a pretty strong track record historically of effective drugs starting off very expensive and then falling in price over time. And then also, something we've worked on in various ways is market shaping, where you actively try to take action that causes prices to go down. Do you think that applies here too? Like if you had to bet, would you bet on prices falling? How do you see that question of like what might happen to prices over time, and what we could do to contribute to prices being more acceptable to countries?

Alice Redfern: Yeah, I think this is actually the space where I've had most of the conversations, and I think partly because, at least at the beginning, by itself, it's not going to look like a GiveWell very cost effective intervention. It's gonna be too expensive at the beginning. So a lot of the case for us is around, what's it gonna look like in a couple of years? So [00:19:00] there's a lot of conversations going on around market shaping. It's not a straightforward path, and I don't think that it's obvious right now exactly what GiveWell's role in that could be.

Elie Hassenfeld: Okay, so I wanna just like zoom out a little bit. The big question we started with is what could GiveWell do and focused a little bit on different kinds of prevention and then focused on this particular prevention mechanism.

We talked at the very beginning about treatment, and we went through it pretty quickly because at the moment, your best guess or a best understanding, is that treatment is relatively more likely to retain funding, and so it seems less promising for us to provide additional funding to.

And then I'm just like curious about the final area that we didn't cover, which is, case finding and testing. And just would love to get your quick thoughts on that and you know, whether that seems like an area that we could end up supporting.

Alice Redfern: Yeah, I think the first thing I'd say is it's in the same bucket as treatment for me and relatively more protected. I think there's probably people who would disagree with me saying that, but it's not seen the same definitive cuts that [00:20:00] the prevention space has.

The other thing I would say is that a big part of finding new cases is this key population outreach, I don't think any of those programs operate completely independently. In fact, when we're talking about these prevention programs, partly there will be people going out and trying to find new cases as part of that as well.

What's interesting is trying to make sure that there's still a supply of tests in the right places at the right time. There's been a lot of progress on making sure that every mother gets an HIV test during the process of antenatal care, and at one point we were quite worried about the supply of those tests and what it was gonna look like, and I think relative to the prevention space, we're a bit less worried right now.

But what I'm consistently worried about is what's gonna happen six months from now. I think that we still don't have much certainty about the US funding space. Things could change in September. You know, PEPFAR was not reauthorized, it's still functioning, but we don't know how that's gonna be reorganized. So I think any of these things could be areas that we would look at, we just need to get up to speed on more areas as [00:21:00] quickly as possible.

Elie Hassenfeld: And so in some sense, what's going on right now is we're looking at this big area, HIV/AIDS, and we're saying, we don't know very much about this. We need to get up to speed.

And then, because we're a relatively small team, we're going to prioritize the areas where we would most expect to be supporting in the future. So maybe we'll like prioritize prevention first, but of course, at the end of the day, what's going to ultimately drive our decision making is what happens with funding and where the needs are.

And so, I don't know, in six months if it turns out that, treatment isn't covered in the way that you're expecting, or there is a need for case finding, then we would shift and focus on that area. You know, really what we're talking about today is just where we're focused now to do our best to prepare for what we see as the most likely future, with the understanding that we could be totally wrong about that and might have to adjust again in the near future.

Alice Redfern: Yeah, I think that's exactly right. We are learning and I think that any initial work that we do in this space, a lot of the goal of that will be for us to learn more about the space. And even within prevention it might be that we find some programs that initially look really promising [00:22:00] to us, and that part of looking at those will be us learning even more.

Elie Hassenfeld: So it seems like the biggest open question right now for us is just, how much funding will be retained for HIV/AIDS into the future, and what programs will that funding support? I'm curious if there are other like really big questions that are on your mind where the answers to the question would have a big effect on what we end up doing in the future.

Alice Redfern: I think maybe this is like a process question for GiveWell almost, but a big thing that we've been talking about is what's the best way to approach this for us? You know, we've spoken about some of the prioritizing we've been doing and how we're looking at it right now, but it's still a really complex space with a lot of variability from country to country and things are not static. And we are not just thinking about HIV on a day-to-day basis.

So just how to approach this. We've been sourcing a lot of feedback from our partners about that, and I think just are really open to ideas about how to go about it. I also think that there's a lot of questions across the whole sector right now around integration, [00:23:00] and this has come up in the HIV space. A lot of country governments wanting to integrate HIV more into their own typical government programming. There was already a push for that within HIV, and PEPFAR was doing a lot of work to try and get that moving in different countries. It's happening even more so, and it's happening at a very rapid and unmonitored, almost, speed.

And I think that's gonna change the landscape in a way that makes it even harder for us to evaluate which programs look good if it wasn't hard enough already.

Elie Hassenfeld: In some sense, historically, a lot of the programs that GiveWell supported, almost bubbled up as being neglected by other funders in one way or another.

So, you know, seasonal malaria chemo prevention had a lot of evidence, and it just wasn't getting a lot of support. You know, this is 10 years ago. Or we can look at something like malaria nets and see that there are parts of Nigeria and Democratic Republic of Congo that just no one is covering and they need funding and we can provide it.

And then HIV/AIDS is different in that, number one, we don't have a lot of historical context on it, so we're trying to figure out how to sprint to get [00:24:00] up to speed so we can make good decisions. And then second, there's just a lot of other actors who themselves are already participating in addressing the problem of HIV/AIDS, but also themselves reconsidering what they should be doing given these changes.

And so, for those two reasons, kind of a different kind of research problem than one we've faced in the past in figuring out where the funding that we're responsible for can do the most good.

Anything else you wanna add before we wrap up?

Alice Redfern: I think I would just add in that we're actively working through this problem at the moment, and we are in touch with a lot of different partners. But if you're listening and you do think of a program that you're running that you think really fulfills these criteria, then you can reach out at research@givewell.org. We are dealing with a lot right now. I can't promise that we'll be, especially fast to respond, but we'll do our best.

Elie Hassenfeld: Great thank you so much, Alice. Appreciate your joining.

Hey everyone, it's Elie again. There are a few things I take away from this conversation. The first is, I think that this whole project is a great [00:25:00] example of what GiveWell is about. GiveWell isn't tied to a particular cause area or program. That is, we're not an organization that focuses on malaria or water per se. Instead, we're just trying to find the places where money goes the furthest, where it can do the most good.

We haven't looked at HIV/AIDS historically, because for all of GiveWell's history, the US government was providing a very large amount of funding to HIV/AIDS. And it just always appeared that funding could do more good in other areas. But now with these cuts, it's possible that HIV/AIDS is an area that we should provide funding to because it has cost effective needs, and because of that, we're looking into it now. So that's really core to GiveWell's core mission to be searching the world, to find the places where money will go the furthest.

I think it also illustrates the real challenges in getting up to speed on a new area. It just takes a lot of time. There's a ton that we do not know about HIV/AIDS. We're doing what we can to move as quickly as we can. We're doing desk research, we're connecting with organizations and researchers and others. It's especially hard right now because of how [00:26:00] much is changing in the space and how much is unknown.

HIV/AIDS is an area that has gotten a lot of attention historically, and so there are many organizations that are all simultaneously trying to figure out how to adapt. And we wanna be sure that the funding we provide is additive on top of those adjustments. And so, you know, it's just kind of a challenging coordination problem, in figuring out where we fit in, and how we can ensure that the funding we direct does a lot of good.

And then for us overall as an organization, in some ways the challenges is even greater, because HIV/AIDS is just one of the areas that may need additional funding due to recent funding cuts. Other areas that we're thinking about include data systems, family planning, and vaccines. And so as a team, we're really stretching to learn about all these new areas as fast as we can so we can consider them for potential funding alongside the areas that we're already funding.

As always, we really appreciate your interest in our work and for listening. If you have any questions or comments about GiveWell in general or about what we talked about here, including advice about how we could do better, [00:27:00] please let us know via an email to info@givewell.org.

If you wanna help people in low income countries, our standard, default recommendation is giving to our Top Charities Fund. The top charities are the organizations, that we have followed for the longest and know the most about. If you're interested in supporting the kinds of programs that Alice and I were talking about today, that's supporting less certain, but high potential work in areas like HIV/AIDS or other new areas, you can do that via supporting our All Grants Fund.

Thank you again for your support and interest in our work. We really appreciate it.