The International AIDS Society—Lancet Commission on the Future of the HIV Response and Global Health

INTRODUCTION

HIV/AIDS has been the most severe and widespread infectious disease pandemic of our time—with more than 75 million people infected, over 40 million deaths, and some 38 million people living with the virus in 2017 and requiring lifelong, daily treatment to stay well.(1) Yet by any measure, the global response to the HIV/AIDS pandemic has been one of the extraordinary success stories of modern medicine, public health, human rights and global solidarity. From an almost uniformly fatal lentiviral infection with a unique epidemiology which killed rich and poor, straight and gay, and women, men, and children in high, middle and low income countries, the HIV response can claim unprecedented successes. By 1996, through intense research efforts and more than 800 clinical trials, effective therapy had been developed to treat HIV infection. In 2002, a concerted effort was launched to provide that treatment globally. By 2016, more than 18 million people living with the virus had been initiated on life sustaining antiretroviral therapy, new preventive interventions have demonstrated remarkable effectiveness, and the response has changed the way research is conducted, essential programs are funded, and human rights protected. With the creation of programs like the Global Fund to Fight AIDS, TB and Malaria, PEPFAR, UNAIDS, and countless community, national, and regional programs, a governance structure for the response has been created and sustained which is unparalleled—and unprecedented in its participation and leadership from people and communities affected by the disease.(2)

Yet the remarkable successes of the HIV response, the vital lessons learned, have arguably not had sufficient impact on global health more broadly. As we enter the era of the Sustainable Development Goals, and face unprecedented threats to the global health and development enterprise, we need to think creatively and critically about how to maintain and expand global health gains and strengthen health systems in diverse and complex development contexts. We have a responsibility as a global community to translate the successes fighting AIDS to the broader global health and SDG agenda while also remaining committed to ending the greatest pandemic of our time. This means actively planning integration with other diseases where the evidence suggests gains could be made, building resilient and sustainable systems for health, and advocating for health care as a human right.

To interrogate these critical issues, The International AIDS Society (IAS) and The Lancet have formed a Commission on The Future of the HIV Response and Global Health. The Commission seeks to investigate several critical questions facing the HIV and global health communities. These include: What is the future of the HIV response in a more integrated global health and development agenda? What have we learned in four decades of battling HIV/AIDS that could inform global health more broadly? What are the real threats to global health and to the HIV response in the current period of declining donor interest, rising nationalism, and global health inequity? And finally, what needs to change to ensure epidemic control of HIV as it increasingly concentrates in marginalized and stigmatized populations?

The IAS-Lancet Commission will interrogate the critical questions of integration and service delivery as HIV is increasingly integrated into health systems. It will explore key domains in global health with relevance to HIV, and propose ways forward for an invigorated and sustainable global health effort. The Commission will seek to provide evidence for concrete action by policy-makers, international bodies, funding agencies, academic institutions, health service providers and communities through compressive review, scenario based modeling, costing, and policy development.

Recognizing the extraordinary diversity that characterizes the current global epidemiology of HIV and the striking diversity of the responses in policies and programs, the commission will address epidemic scenarios as diverse as the expanding epidemics among people who inject drugs in Russia and Ukraine, the high burden epidemics among reproductive age adults in the strained health systems of Southern and Eastern Africa, and the complex key population epidemics which continue in multiple highly diverse middle and upper income countries across North and South America and South and Southeast Asia.(3)

This Commission builds on a Lancet—IAS Symposium Session at the 9^th IAS Conference on HIV Science 2015 in Vancouver, Canada, entitled “AIDS for Global Health,” which was an initial attempt to assess the lessons learned from the AIDS response for global health efforts, and to explore the position of the HIV response in the SDG era.[4] This session included Richard Horton, Editor-in-Chief of The Lancet, Dean Michael Klag of Johns Hopkins Bloomberg School of Public Health, Diane Havlir and Dathan Byonanebye from the SEARCH (Sustainable East Africa Research in Community Health) study, and others who explored the synergies and challenges of integration and the potential downsides of an end to “AIDS exceptionalism.” The Commission has engaged thought leaders in an array of global health disciplines, and included experts in health systems, finance, women’s health and rights, chronic diseases, and HIV related infections, including TB, viral hepatitis and STIs.

The Commission will be co-chaired by IAS immediate past president Chris Beyrer, and Linda-Gail Bekker, current IAS President. The commission will report on its findings in The Lancet, and at the upcoming 22^nd International AIDS Conference in Amsterdam, in July 2018.