Countries most affected by HIV must focus on stopping new HIV infections and expanding access to antiretroviral treatment or risk the epidemic rebounding, urges a major new report from the UNAIDS and the Lancet Commission.
“We must face hard truths – if the current rate of new HIV infections continues, merely sustaining the major efforts we already have in place will not be enough to stop deaths from AIDS increasing within five years in many countries,” said Professor Peter Piot, director of the London School of Hygiene & Tropical Medicine, co-chair of the commission, and lead author of the report. “Expanding sustainable access to treatment is essential, but we will not treat ourselves out of the Aids epidemic. We must also reinvigorate HIV prevention efforts, particularly among populations at highest risk, while removing legal and societal discrimination.”
While unprecedented progress has been made to increase access to HIV treatment globally, the report shows that the rate of new HIV infections is not falling fast enough. This, combined with high demographic growth in some of the most affected countries, is increasing the number of people living with HIV who will need antiretroviral therapy to stay alive.
“We have to act now. The next five years provide a fragile window of opportunity to fast-track the response and end the Ads epidemic by 2030,” said Michel Sidibé, executive director of UNAIDS and co-convenor of the commission. “If we don’t, the human and financial consequences will be catastrophic.”
While there is scope in many countries for greater shared responsibility by increasing funding for HIV, the report clearly shows the urgent need for substantial global solidarity to front-load investments. The need for investment is particularly acute in low-income countries with a high HIV burden.
Among the sobering findings from the report is that sustaining current HIV treatment and prevention efforts would require up to 2% of GDP, and at least a third of total government health expenditure, in the most affected African countries from 2014 to 2030 to fund HIV programmes. This clearly demonstrates that international support to the Aids efforts in these countries will be needed for many years to come. However, there is also a pressing need to ensure that people are not left behind in middle-income countries, which can and must do more to sustain their HIV prevention and care programming in higher risk, often marginalised populations.
If the most is made of this five-year window of opportunity, HIV transmission and Aids-related deaths could be greatly reduced and mother-to-child transmission virtually eliminated by 2030. This will not only require an increase in resources, but also a more strategic and efficient use of those resources.
HIV programmes have a maximum effect when used in combinations that are tailored to the needs and contexts of populations at higher risk and in geographical locations with high HIV prevalence, as is now the policy in countries such as Kenya. At the same time, synergies with mainstream health services are needed, and a long-term view to ensure sustainability of achievements, including high quality antiretroviral treatment. Also recognising extraordinary innovation in the Aids response, the commission calls for leveraging lessons learned in the Aids response to be applied to new and existing global health challenges. “The movement created by the Aids response is unprecedented – a system of checks and balances from a people-centred approach is one that more global health institutions should adopt. Identifying multi-sectoral stakeholders early will save time and money by ensuring the best solutions reach the right people,” said Lancet editor-in-chief and co-convenor of the commission Dr Richard Horton.
The report is critical of countries that have become complacent, highlighting that some countries with previously stable or declining HIV epidemics have shown trends of increasing risky sexual behaviours among at-risk groups over the past five years, with new HIV infections on the rise. For example, recent studies have found clear evidence of resurgent HIV epidemics among men who have sex with men in Western Europe, North America, and Asia. In Uganda, national trends in new HIV infections have started to reverse and rise again after a decade of growing successes, in part because of a decreased focus on HIV prevention.
The report makes seven key recommendations, leading with the urgent need to scale up Aids efforts, get serious about HIV prevention, and continue expanding access to treatment. Other recommendations include efficient mobilisation of more resources for HIV prevention, treatment, and research, and for robust, transparent governance and accountability for HIV and health. The Aids response must continue to be grounded in human rights, and practical solutions are needed to expedite changes in laws, policies, and attitudes that violate the rights of vulnerable populations, and that stand in the way of an effective Aids response.
The report says that an estimated 2.1m people were newly infected with HIV globally in 2013, reports Livemint. People living in 15 countries – Brazil, Cameroon, China, India, Indonesia, Kenya, Mozambique, Nigeria, Russia, South Africa, Uganda, Tanzania, the US, Zambia, and Zimbabwe – accounted for more than 75% of these new infections. Nearly 61% of the world’s 35m HIV/Aids cases live in these countries and India is the third highest with 2.1m patients.
According to the AIDSinfo, a US health department project that provides information on HIV/Aids clinical trials and treatment, only South Africa and India provide more than half of current HIV spending. The remaining countries contribute only 16% of the funding for HIV, yet account for 37% of all people living with HIV in low-income and middle-income countries.
Ten countries have over 1m people living with HIV according to the report. The Aids response in these 10 is incomplete and there is a large funding gap, which is projected to grow. For example, only 38% of all people living with HIV in these countries are now receiving ART – the most costly component of the AIDS response – yet eventually, all will need it.
Middle-income countries are already increasingly using domestic investments to fund their Aids responses. Brazil, China, India, Russia, and South Africa, for example, increased their domestic HIV spending by more than 120% between 2006 and 2011. The report calls for a combination of renewed and stronger political commitment and targeted funding to regain control of resurging HIV epidemics.
“Health systems are fragile in some middle-income countries, and the transition from external to domestic funding therefore needs to be carefully managed to ensure that the health-care needs of people living with HIV, especially those treated with ART, continue to be met,” said the report.