HIV: From Exceptionalism to Endgame

25 July 2018 by Peter Sands, Executive Director of the Global Fund

Advancing global health and strengthening the HIV response in the era of the Sustainable Development Goals: the International AIDS Society–Lancet Commission 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. 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.

Full article in The Lancet.