The Global Progress on HIV and AIDS and the Work That Remains

Liza Solomon, DrPh
Principal Associate, U.S. Health Division

Catherine Thompson, MPH
Principal Associate, International Health Division
The contrast was stark. At the 2000 International AIDS Conference in Durban, whose theme was “Breaking the Silence,” South Africa’s government was in a state of denial about the epidemic in their country and the fact that HIV causes AIDS. Delegates walked out to protest the government’s policy.
Flash forward to 2016, when Durban again was the host city and the theme was “Access Equity Right Now.” Today South Africa has more than 12 million people in treatment and the world’s largest treatment program. Globally, the life expectancy of an HIV-positive person is the same as that of an HIV-negative person. While just 42 percent of adults are on anti-retroviral drugs, this progress overall shows what domestic leadership and commitment, combined with international aid and know-how, can accomplish. Hence keynote speaker Charlize Theron opened the conference by asking, “Why do we have to keep meeting this way?”
Despite—and in some ways because of—the success in South Africa and worldwide in the fight against AIDS, much work and many challenges remain. The success, plus many nations’ move from low- to middle-income status, may prompt donors to reduce funding when the threat is far from over. There is no assurance that countries will be able to take over donor-implemented programs or that they actually have the needed funds available to meet the still significant HIV prevention and treatment challenges.
Despite significant technological innovations like point of care viral load, HIV self-testing and the push for better treatments such as Bill Gates’s call for super-long lasting drugs, significant obstacles to applying these breakthroughs and practices persist at all levels. The challenges range from biological obstacles and high drug prices to an inadequate supply of community-level health workers. 
The focus of the conference and increasingly of donors was on the rights of key populations where the epidemic is concentrated: men who have sex with men, intravenous drug users, sex workers, and transgender people. The conference highlighted issues surrounding the transgender population, which has a shockingly high rate of HIV prevalence, often lacks access to appropriate services, faces significant stigma and violence, and has uncertain interactions of hormones regimes and anti-retroviral drugs.

More Funding for Education Needed

But the welcome focus on vulnerable populations may reduce funding for education of the general public. Campaigns in schools and places where youth gather, mass media campaigns, and community-level communication all remain necessary—and can be expensive. By not investing more in the general population’s awareness of the disease—even though it might not seem cost effective at the moment—we run the risk of an entire generation that would not know much about the disease or take the risk of HIV seriously.
Without this education, for example, youth may not take available measures to protect themselves, potentially setting the stage fora sharp increase in transmission. Such educational efforts take money. To avert a decline in donor funding, experts advised donors against using national income classification as a basis for funding. And recipient countries received encouragement to use their new resources to respond to HIV and AIDS needs. There were repeated calls for full funding of the Global Fund.
The conference was not all downbeat. It is expected that 73 percent of the HIV positive population will be virally suppressed by 2020 - making great progress towards the UNAIDS 90-90-90 goal, where 90 percent of all people living with HIV will know their HIV status, 90 percent of all people with diagnosed HIV infection will receive sustained antiretroviral therapy, and 90 percent of all people receiving antiretroviral therapy will have viral suppression.
Grupos de Apoio a Adesão Comunitária, or community adherence and support groups, show promise in helping patients stick to their drug treatment in Mozambique. Similarly, pre-exposure prophylaxis (PrEP) is expensive, but research trials and real-world examples show it can work. PrEP thus offers an enormous opportunity to provide an effective prevention strategy for HIV- negative individuals, though researchers need to study its effects on other sexually transmitted diseases. Voluntary medical male circumcision also was a hot preventive topic. 
The combination of increased numbers of infected people on treatment and effective prevention for HIV-negative individuals at risk offers the possibility of controlling and eventually achieving and AIDS-Free Generation—if funding doesn’t dry up. 
Other contributors to this blog include Sophie Faye, Gafar Alawode, James White, Katherine Brouhard and Stan Crock.
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