Response to HIV/AIDS epidemic at risk of 'dangerous complacency' as urgent change in approach is needed

Changes to the HIV response are needed to win the global fight against HIV, and the authors propose that HIV researchers and health care professionals need to work more closely with their counterparts in global health, HIV services need to be included into wider health services, and global health policies need to incorporate HIV.

The report combines the expertise of more than 40 international experts who make recommendations for how HIV and global health can work together to advance global health and improve the HIV response. The report also models the impact of combining HIV within other health services in five countries, and is being presented at the AIDS 2018 conference in Amsterdam.

Growing threats in HIV and global health

HIV is the epidemic of our time, with up to 38.8 million people living with HIV worldwide in 2015-2016, and around two million new cases diagnosed in 2015. There were one million AIDS-related deaths in 2016, and overall more than 35 million people have died of AIDS-related causes since the start of the epidemic.

Worldwide, 44% of all new HIV infections occurred in people from marginalised groups (such as gay and bisexual men, people who inject drugs, sex workers, transgender people, and the sex partners of people in these groups), and health systems struggle to reach and engage these groups. Additionally, as health systems struggle to provide adolescent-friendly services, adolescents are at risk of HIV infection, particularly girls and young women. In sub-Saharan Africa, the risk of HIV infection peaks at age 15-24 years for adolescent girls and young women, and AIDS is the fourth leading cause of death for this group.

The HIV epidemic remains prevalent in these populations and in countries where health systems struggle to provide the necessary services. New infections are declining, but far too slowly to reach the UNAIDS target of 500,000 new infections by 2020. From 2010-2017, new infections declined by 16% to 1.8 million per year worldwide, but remained substantially higher for younger women then young men [1]. The Commission authors warn that a resurgence of the epidemic is likely as the largest generation of young people age into adolescence and adulthood.

At the same time, care for HIV is also changing as the population of people with HIV is steadily growing older due to the effectiveness of antiretroviral therapy (ART). Between 2012 and 2016, the number of people older than 50 years living with HIV increased by 36% worldwide. As this group have an increased risk of many age-related diseases (such as cardiovascular disease, neurocognitive disorders, renal disease and some cancers), a focus on prevention and management of non-communicable diseases (NCDs) for people with HIV is needed, creating a crossover with global health and wider health services.

HIV funding has remained flat in recent years, at about US$19.1 billion, roughly US$7 billion short of the estimated amount needed to achieve the UNAIDS 90-90-90 targets [2]. This is happening as a growing number of people are receiving ART and will require sustained access for decades to come -- in June 2017 approximately 20.9 million people worldwide were receiving the drugs (57% of people with HIV), increasing from 680,000 people in 2000.

However, there are also wider issues in global health that add to these problems. "Global health is beginning to falter as democracy, civil society, and human rights deteriorate in many countries, and as development assistance for health has stalled. This loss of momentum comes as health systems need to become stronger to contend with the growing numbers of non-communicable diseases," says lead Commissioner Dr Linda-Gail Bekker, President of the International AIDS Society and Professor at University of Cape Town, South Africa.

"The HIV response and the broader global health field must work together. Despite the remarkable progress of the HIV response, the situation has stagnated in the past decade. Reinvigorating this work will be demanding, but the future health and wellbeing of millions of people require that we meet this challenge," she adds. 

Exceptionalism and the future

The authors call on HIV and global health researchers, health care professionals and policy makers to work together to improve the HIV response, arguing that this may be essential to achieve ambitious global HIV targets to end HIV by 2030 [3], maintain treatment access, and more effectively fund the HIV response to also benefit broader health outcomes. The authors call for immediate increased funding to avert another epidemic, and while they recognise that the 'exceptionalist' approach of the HIV response (where specific funding and health services have been provided for HIV alone) has been highly effective, they note that the approach may not be sustainable in the future.

They use mathematical models to examine the benefits of combining HIV with other health services, such as screening for HIV alongside screening for diabetes, high blood pressure and other NCDs, integration of HIV into reproductive and sexual health services, and harm reduction and overdose services.

In Kenya, approximately 1.6 million people are living with HIV, and around 30% of cases remain undiagnosed. At the same time, there is an increasing burden of NCDs (accounting for 27% of all deaths and 50% of all hospital admissions), which is largely due to a lack of early detection, meaning that people are diagnosed late and have poorer treatment outcomes.

The authors modelled combining screening for HIV, high blood pressure and diabetes. They estimate that, if the combined screening reached 10% of the Kenyan population every year over the next decade (2018 to 2028), and ART coverage reached 78% by 2028, over 216,000 new HIV cases and 244,000 AIDS deaths would be averted. This would also identify 686,000 individuals with untreated diabetes and 7.57 million people with untreated high blood pressure during this period. Setting up the screening programme would cost US$56.8 million for HIV testing and $3.2 million for NCD testing in the first year of the programme (2018). The authors estimate that the intervention would be cost-effective with respect to both HIV-related and NCD-related outcomes, but would require substantial health care resources to meet demand.

In India, if HIV testing, ART, and pre-exposure prophylaxis (PrEP) were combined with testing and treatment for syphilis for female sex workers and men who have sex with men (MSM), this could reduce the number of new HIV cases at a national-level by 7% between 2018-2028, potentially averting 51,000 new infections (including 43,000 in MSM, but fewer new infections in female sex workers as incidence is already projected to decrease rapidly). It could also avoid 81,000 AIDS-related deaths (including 59,000 in MSM, and 6,200 in female sex workers) between 2018-2028.

Adding PrEP into the intervention is estimated to have limited additional benefits due to the large preventive effects of ART. However, including testing and treatment of syphilis is estimated to diagnose and treat more than 510,000 new syphilis cases in female sex workers and MSM in 2018 alone, but the long-term effects would depend on infection and re-infection rates. Therefore, the authors estimate that combining HIV testing and treatment with syphilis screening and treatment would be highly cost-effective, but adding PrEP to this intervention is not cost-effective.

Finally, in Russia, increased medication-assisted treatment, needle and syringe programmes, and providing ART to 50% of people who inject drugs in the two high risk areas of Omsk and Ekaterinburg, could avert 53% and 36% of new HIV infections between 2018-2028, respectively. Integration of HIV services with medication-assisted treatment could also avert one-third of all fatal opioid overdoses -- a major cause of mortality among people who inject drugs in Russia and globally. However, cost-effectiveness of this model was not estimated.

"Health systems must be designed to meet the needs of the people they serve, including having the capacity to address multiple health problems simultaneously. No one can be left behind in our efforts to achieve sustainable health. We must recognise health as an investment, and increase resources to support stronger, sustainable, and people-centred health systems," says co-chair of the Commission Professor Chris Beyrer, John Hopkins Bloomberg School of Public Health, USA, and past President of the International AIDS Society. "The HIV community must make common cause with the global health field. The HIV response's multidisciplinary, inclusive approach, its engagement of civil society, emphasis on human rights and equality, galvanisation of scientific innovation, and global collaboration are important elements that could revitalise global health's aim for sustainable health for all."

Writing in a linked Comment, Peter Sands, Global Fund to Fight AIDS, Tuberculosis and Malaria, Switzerland, welcomes the Commission, but highlights that there will be barriers to be addressed in this integration. He says: "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."

Writing in a Lancet Comment reflecting on the Commission, Dr Pamela Das, Senior Executive Editor, and Dr Richard Horton, Editor-in-Chief of The Lancet, say: ." ..it is now time to end the siloed and vertical response to AIDS, and, in the words of the Commission, to "make common cause with the global health field." That conclusion raises many questions about the existing instruments to address the AIDS epidemic -- namely, UNAIDS, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the US President's Emergency Plan for AIDS Relief (PEPFAR). We invite these major institutions that are instrumental in driving the AIDS response to reconsider their purpose and their future. We encourage their respective leaderships to reassess their missions and to move towards a broader global health purpose, while at the same time sharpening their commitments to HIV/AIDS. With an upcoming replenishment in 2019, the Global Fund should continue to push hard for extra funding for HIV/AIDS. But the Global Fund should also think about how to broaden its response to include wider aspects of global health. This approach would support the idea that investing in the AIDS response is a means to building stronger health systems, getting to universal health coverage, and deepening access to services beyond HIV/AIDS."

[1] http://www.unaids.org/sites/default/files/media_asset/20170720_Data_book_2017_en.pdf

[2] The UNAIDS 90-90-90 target aims for 90% of all people living with HIV to know their HIV status, 90% of all people with diagnosed HIV infection to receive sustained antiretroviral therapy, and for 90% of all people receiving antiretroviral therapy to have viral suppression by 2020.

[3] As part of the SDGs, UN member states have pledged to end the AIDS epidemic as a public health threat by 2030, which has been defined as reducing the number of new HIV infections and AIDS-related deaths by 90% compared with 2010.