HIV: from exceptionalism to endgame

Advancing global health and strengthening the HIV response in the era of the Sustainable Development Goals: the International AIDS Society–Lancet Commission¹ is a timely and compelling analysis of where we stand in the fight against HIV, and how the exceptionalism of the HIV effort should evolve in response to the Sustainable Development Goals (SDGs).

As the Commission's report makes clear, we are not on track to end the HIV epidemic by 2030. We can still reach that goal, but only if we commit more funding and improve the way we do things. Simply continuing as now, with an insufficient emphasis on HIV prevention and inadequate financial resources will not get us there. Although the massive expansion of antiretroviral treatment has saved millions of lives and slowed the epidemic, more assertive action is needed to turn off the tap of HIV infections. In southern and eastern Africa, the cycle driving HIV infections in adolescent girls and young women must be broken.² Elsewhere in the world, and particularly in eastern Europe and Central Asia, criminalisation, stigma, and neglect are causing HIV infection rates to rise again among key populations, such as men who have sex with men, people who inject drugs, sex workers, and transgender people. Without tackling the deep-rooted human rights and gender-related barriers to accessing health services, we will not quell these concentrated epidemics.

The need to revitalise the battle against HIV is one reason HIV programmes must be better integrated with initiatives to strengthen the health system as a whole. Even if we mobilise more resources, we must make our interventions more effective, maximising the impact of every dollar. Achieving this means strengthening fundamental capacities, including the numbers of qualified health workers, data systems that enable granular analysis, financial mechanisms that ensure funds are deployed where they are needed, and supply chains that reliably deliver the right drugs. Purely vertical efforts to fight HIV will win battles but not the war.

Another reason for better integrating HIV programmes with other initiatives to strengthen health system performance is to leverage and learn from the exceptionalism of the response to HIV. To an extent unprecedented in global health, the fight against HIV/AIDS has engaged civil society, stimulated innovation, mobilised unprecedented resources, and relentlessly focused on impact. A powerful sense of global solidarity inspired the creation of institutions such as the US President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the mobilisation of billions of dollars of international assistance. Infusing the broader SDG3 agenda with the strengths of the HIV response would help bridge the yawning gap between vision and reality in global health.

The challenge is how to achieve this deeper integration without diluting what has made the HIV response so successful. If mainstreaming HIV programmes into other health services makes them less focused on outcomes, or diffuses engagement, we will go backwards.

The report of the International AIDS Society–Lancet Commission provides powerful insights into how HIV programmes can be more effectively integrated into the SDG3 agenda. Depending on the context, HIV interventions can be combined with programmes for sexual and reproductive health (eg, for adolescent girls), for associated diseases, such as hepatitis or tuberculosis, for health services for young men, and even for non-communicable diseases—not least because people on long-term antiretroviral therapy are susceptible to cardiovascular and other non-communicable ailments.³ Supply chains, community health workers, and other capacities built to achieve HIV goals can be evolved to support other health objectives, including reinforcing resilience against infectious disease outbreaks, such as avian influenza, severe acute respiratory syndrome, or Ebola virus disease.

© 2018 Adriane Ohanesian/Reuters

Working with our partners, the Global Fund has already embarked on this path of targeted integration. However, there are challenges in scaling up such approaches. Integrative programmes need to be thoughtfully designed, with a clear logic and metrics. This is harder than simply rolling over what has been done before. We need to overcome persistent professional and bureaucratic silos. The biggest challenge is money. The expansion of antiretroviral treatment has been a huge success, but although drug costs have been reduced, supporting an ever-increasing population on antiretrovirals for the rest of their lives means much of the funding for HIV is committed to purchasing health commodities.

I welcome the Commission's support for continued robust funding of the Global Fund and PEPFAR. Yet the most urgent priority is to increase national funding. While some countries have taken important steps to increase domestic resources, including innovations such as Zimbabwe's AIDS levy,⁴ overall fiscal mobilisation for health in many low-income and middle-income countries is dismally short of what will be required to turn SDG3 into a reality.⁵ We can leverage scientific advances and innovations, but we shouldn't expect miracles. Ending the HIV epidemic will take more money. Achieving the SDG3 goal of universal health coverage will require even more.⁶ We must rediscover the energy and global solidarity that inspired the exceptionalism of the HIV response, expanding its reach to encompass SDG3. We must build people-centred health systems while maintaining laser-like focus on achieving results.