Great progress, but… An array of academics and activists take a snapshot of the state of the global response to HIV and TB.
“I am tired – to the point of despair – of all the congratulatory public raptures about the progress against HIV and Aids. How could we not have made progress? It’s been thirty-six years, for heaven’s sake: we were bound to move forward. Instead indulging in an orgy of self-hypnotic success, we should be demanding to know how it’s possible that up to 19m people still don’t have treatment; that women and adolescent girls continue to bear the brunt of the pandemic’s assault; that key populations are demonised by fossilised governments, so that prevention and treatment are never available; and that we’re in a staggering funding crisis, the sure outcome of which is even greater morbidity and mortality. Where is the political and multilateral leadership that can decisively and forever turn the tide? We should all be raging against the profusion of fatuous voices.” – Stephen Lewis, co-director, AIDS-Free World
“The world has made great strides in tackling HIV/Aids, but we are in danger of coming to a standstill. Progress has slowed, for a variety of reasons; but a major roadblock is our failure to listen to young people. The largest-ever generation of adolescents in sub-Saharan Africa is at risk of HIV – in 2015, nearly 7500 young women aged 15 to 24 years acquired the infection each week. Stigma, poor education, and services that are out of touch. We must understand what young people are going through, and react quickly and effectively, if we are to end HIV/Aids.” – Professor Peter Piot, director of the London School of Hygiene & Tropical Medicine and former executive director of UNAIDS
“In 2008, when the global economic crisis hit, funding for HIV and TB first plateaued and now is slowly declining. If the 2000s offered the promise of ‘the end of Aids’ and new strides against TB, in the next few years we may be trying to figure out how to ‘do less harm’, and limit the damage that funding cuts will cause after promises made by donors have been broken and allocations curtailed. I can’t offer you false hopes about us getting to 90-90-90 anytime soon, but perhaps the brutal facts will spur us to action once again; they are surely better than spooning out comforting – and ultimately, untrue – platitudes for World Aids Day.” – Gregg Gonsalves, long-time Aids activist and assistant professor, Yale School of Public Health
“A bittersweet trajectory – We are in an epoch in which the HIV epidemic continues in an unremitting manner, eradicating the promise of a better tomorrow from our families and communities. In our country, more than 7m people are HIV-infected; and it is estimated that there are 1,000 new infections every day. Science continues to push the boundaries: progress new HIV treatment and care interventions, movements to control paediatric HIV by reducing maternal-foetal HIV transmission. These have translated into reductions in infant and under-five mortality rates, and increased life expectancy. In the HIV-prevention arena, progress in long-acting antiretrovirals for use in pre-exposure prophylaxis may translate into a powerful prevention intervention. As we advance three HIV vaccine concepts into efficacy studies, we start to think that we may have the kind of tools that have the potential to curb the HIV epidemic globally. However, the biggest hurdle to overcome in our fight against HIV is the stigma and discrimination that HIV-infected people face every day of their lives. The true test of beating this epidemic will be whether we as a people have the ability to overcome our prejudices against people living with HIV. While we have at our disposal a series of proven prevention tools to afford us safer sexual choices, it is evident that science and biomedical interventions alone will not help heal our communities and families. Structural factors such as poverty and unemployment, in addition to biological factors such as genital inflammation and viral load, and behavioural factors such as lack of condom use and age-disparate relationships, have combined to make our battle against HIV all the more challenging. If we are to grow the momentum of our battle strategy against HIV, then we must not define people by their living with HIV; but rather, by the lives they fulfil.” – Professor Glenda E Gray, president of the South African Medical Research Council
“HIV and TB continue to be major global public-health issues, with an estimated 37m people living with HIV and an estimated 10.4m with TB. The vast majority of people living with HIV and TB are from the low and middle-income countries, and the majority of them are public healthcare users. We can’t afford to lose this battle; political rhetoric without action won’t win this battle. The only revolutionary step towards ending HIV and Aids is to invest more resources in public health care, and have the political commitment and will required to overhaul public healthcare systems. Only a functional, well-maintained, well-resourced public healthcare system that will serve the people – irrespective of their class, sexual orientation, financial status and of other discriminatory laws – can take us to where we want to see ourselves with our global response to HIV and TB.” – Anele Yawa, general secretary, Treatment Action Campaign
“In 2017, it is very encouraging to see expansion of life-saving antiretrovirals to 21m individuals worldwide; however, in order to get the full impact of this treatment expansion, we also need to ensure that all 21m stay on their treatment and become virally suppressed. Sadly, we are not doing well in tuberculosis and without a doubt more emphasis is needed worldwide on improving primary prevention of both HIV and tuberculosis. This will require that we also address structural determinants of universal health: a much harder challenge to meet.” – Professor Linda-Gail Bekker is the president of the International AIDS Society and deputy director and chief operating officer of the Desmond Tutu HIV Foundation at the University of Cape Town
“South Africa has the largest HIV treatment programme in the world with 4.2m patients on treatment. This has been achieved through a combination of factors including high levels of activism by civil society formations, political leadership from Minister Aaron Motsoaledi, funding from national Treasury in the form of a conditional grant, training of nurses to initiate patients on first line treatment (NIMART) and support from development partners. However, with an estimated 270 000 new HIV infections in 2016 as well as 7.1m living with HIV and Aids, it is clear that we have much more to do in both preventing new HIV infections as well as reaching the 90-90-90 targets by 2020. The recently launched Global HIV Prevention Coalition’s HIV Prevention Roadmap proposes a target of no more than 88,000 new HIV infections by 2020. In addition, reaching the 90-90-90 targets means that we should have 6.2m patients on ART by 2020 as well. To meet these targets we will require that all stakeholders fully commit to them, find additional resources as well as work collaboratively. It will also require changes to how we provide services to reach the treatment targets and how we support patients to ensure high levels of viral suppression. We also need to more rapidly decrease new HIV infections by being more creative and fully implementing combination prevention strategies. Our strategies must include dealing decisively with the TB epidemic as well – preventing new TB infections, finding those that have TB and successfully treating them. We have the political will, the motivation, and the means to reach epidemic control by 2020!” – Dr Yogan Pillay, deputy director general, South Africa, National Department of Health
“The state of the intertwined, global HIV and TB response is characterised by two signature themes. In the first instance, we have a global community unified in strategic intent to achieve epidemic(s) control, as encapsulated by the UNAIDS 90-90-90 strategy. This unified focus needs to be bolstered even further, as the impact of a successful 90-90-90 strategy will be healthy, HIV positive persons living long, productive lives, while transmitting the virus at far lower rates. The second signature theme relates to generalised insecurities globally, and the emerging dominance of more conservative, inward-looking views among donors. This directly affects the HIV/TB programmes that support the poorest and most marginalised of communities. Efforts should be amplified towards lobbying wealthy countries to increase donor support to developing countries, while developing countries should find greater internal resources to support the same. HIV/TB epidemic control requires long-term, global, sustainable support by – and for – all.” – Dr Tim Tucker is CEO of SEAD Consulting and specialist clinical virologist
“Thanks to anti-retrovirals, Aids is no longer an inevitably fatal condition, but a chronic, manageable one; rates of infant transmission have been reduced to about 1.5%; and their impact on prevention – directly through viral suppression of infected persons, or through prophylactic use by infected persons – is starting to emerge. Though with nearly 20m people still to be initiated on treatment globally, 1m deaths, and 1.8m new infections still continuing to occur, we can hardly claim to have turned the corner or the tide! We do have sufficient knowledge to achieve epidemic control, however in sub-Saharan Africa, the HIV and TB epidemics are closely intertwined; failure to integrate HIV and TB services is resulting in continued high mortality rates – as are stigma and discrimination, through creating a barrier to accessing services. Stigma remains a major barrier to access to services. We need to partner with infected and affected communities much earlier, and across all stages of developing, evaluating and implementing new interventions. Getting to this point has required a lot of teamwork, political commitment, global solidarity and innovation – and the next phase is going to be a lot more challenging. But can we afford to reverse the gains made to date?” – Quarraisha Abdool Karim is the associate scientific director of CAPRISA in South Africa
“The political momentum for the fight against TB is now garnering the same type of global attention that HIV achieved in 2000, when the UN General Assembly hosted a Special Session on Aids, the Global Fund was created, and investments shifted from the millions to the billions. It’s not before time. Still lagging behind is any serious attention being paid to the plight of women and girls. In fact, things are going into reverse: in January 2017, US President Trump used his first days in the White House to expand the Global Gag Rule to all $8.8bn allocated to US global health – including funds dedicated to HIV and TB. This is likely to have a devastating impact on the lives of girls and women, especially girls and women impacted by these two diseases. NGOs registered outside the US can no longer provide information or advice about safe abortion, even with their own or other people’s funds, if they want to retain funding flows from the US. All of the hard work done so far to address the human rights of girls and women, and to break through silos, has been endangered. Many HIV programmes have worked hard to address the needs and rights of the women and girls they serve, so that they can access the full spectrum of sexual and reproductive health services alongside their HIV and TB services. Given the heavy reliance of HIV and TB programmes on US funding, catastrophic impacts are predicted that will be counted in the lives and well-being of women, girls and their communities. Brave politicians – initially from the Netherlands and other European countries, and now from Canada, Afghanistan and a range of African countries – have mobilised. Around the world, thousands of individuals and organisations are standing together under the banner of SheDecides to fight for a ‘new normal’, in which every girl, every woman, everywhere decides for herself what to do with her body, her life and her future. And you can join them, by signing the manifesto at www.shedecides.com.” – Robin Gorna co-leads SheDecides
[link url="https://www.spotlightnsp.co.za/2017/12/01/state-global-hiv-tb-response-december-2017/"]Spotlight report[/link]