For the first time in history, significant scientific advances mean that we have the potential to cut HIV, tuberculosis and malaria down to low-level epidemics, something the human family could not have imagined only 10 years ago. We are not there yet and the window of opportunity will not stay open for too long, so we need to act quickly and use wisely the tools at hand.
A critical mass of epidemiological intelligence is revolutionising our understanding of HIV, providing the global health community with an opportunity to laser-guide the right health interventions to the right populations. Geographical and epidemiological mapping is suggesting that HIV is being pushed into concentrated pockets amid a sea of much lower levels of infection. In Kenya, for instance, the risk of infection can vary ten-fold from one county to the next, while within one of the highest prevalence corners of South Africa up to a third of infections may occur within just 6 per cent of the area. People marginalised by society, sometimes even criminalised, live in these dark corners, often without full access to health care. Whether in Africa, Latin America, Asia, Europe or the United States, populations suffering from the highest HIV infection rates and prevalence rates are the ones that are being left behind, defying global hopes about the possible end of AIDS. These populations usually include young women, men who have sex with men, people who inject drugs, sex workers and prisoners. In these groups, we can sometimes see rates of as high as 30 or even 40 per cent HIV prevalence in some parts of sub Saharan Africa, even while prevalence among the general population can be as low as 1 per cent. Using this data, ministers of health and finance, heads of state, development partners and civil society leaders are working in close partnership to structure interventions around the foci of transmission to maximise health investments.
Our epidemiological knowledge is telling us that to succeed in turning the HIV pandemic into a low-level epidemic we need to target and prioritize our interventions by tackling those pockets. Computer modelling suggests that impact could be increased by 20 per cent, simply by directing resources to the populations at greatest risk of infection and transmission. By following this approach, it is possible that a highly successful program could drive as much as a 70 per cent reduction in new infections by the year 2029. Prioritizing resources to those foci can radically improve efficiency, generating more health for the same budget. This is exactly what the Global Fund’s new funding model is putting front and centre. This new approach to funding will give the global community the ability to identify and tackle HIV in its remaining strongholds.
Partners in the fight against HIV have fought tirelessly to bring down infections and signs of success have been emerging in a growing number of countries. Such reductions are important in their own right, but they can also “soften” the epidemic by reducing the strength of transmission. If we harness the funds needed and direct our health interventions towards the most vulnerable groups, we can make the HIV epidemic much more fragile, so that future generation of vaccines and technologies can deal the epidemics a fatal blow. A partially effective vaccine would not have much of an impact against a roaring epidemic, but it could make it possible for a weakened epidemic to reach a tipping point.
Not only scientific advances and the programs that have been developed over just the last few years are making it possible to defeat the disease. So are the falling costs of medication. The price of the preferred set of antiretrovirals has fallen by 70 per cent since 2007, while the cost of delivering ART has dropped by 11 per cent per year for the last decade. This is because clinics are maturing and learning by doing and supply chains are becoming more efficient.
All this is very exciting, but we need to be conscious that these windows of opportunity don’t stay open for very long. The economics of HIV interventions mean that, as we begin to see downturns in infection levels, now is the time to invest: the interventions we need would not be possible if we returned to a phase of rapid epidemic growth. If international funding to Zambia, for instance, were to be frozen or cut, we would see a rapid bounce-back, with 700,000 additional new infections and 400,000 deaths by 2030, reversing the enormous progress made in recent years. So as the world enters what could be a final stretch in the fight against this modern-time plague, our challenge is to invest smartly, follow the epidemiology and build up the systems that have been in place over the last years to make sure we reach all risk groups and geographical areas to get to low-levels of HIV transmission.
Opportunities to cut down a pandemic don’t come often. So let’s make sure we don’t leave anybody behind.