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World AIDS Day: Four steps to achieve epidemic control

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World AIDS Day 2015 marks an unheralded but profound increase in our response to HIV and other major infectious diseases. In the last year, HIV diagnostics and medicines have made a real step change, as better and cheaper viral load tests and lower-dose, less toxic, more effective and cheaper drugs come to market. Drug costs are at their lowest ever, with generic first-line regimens costing $95-158 per patient per year – a 60-70% reduction from 2007-2014.

We now have a combination pill with a protease inhibitor that is less toxic and as efficacious as multi-pills. Viral load tests have been negotiated down to $9.40 in South Africa. In tuberculosis care, a field where drugs and diagnostics have stood still since after World War II –yes, for the last 70 years-- we now have the Xpert test and new classes of drugs that are better tolerated and which are increasing multi-drug resistance clearance rates from below 50% to almost 80%.  We also now have access to highly effective treatments for Hepatitis C virus and a promising SanofiPasteur Dengue vaccine is in development.
Financing for treatment and care of infectious diseases is challenging but may be navigable. International development financing for HIV in particular has been more robust than feared after the global financial crisis of the 2000s and has stabilized at approximately $8 billion a year. Domestic HIV financing has grown, particularly in Brazil, Russia, India, China and South Africa (the BRICS) and upper middle-income countries, with slower growth in lower middle-income and lower-income countries.
Program coverage is expanding faster than ever, but daunting gaps remain. Approximately 16 million people now receive AIDS treatment, but half of those with HIV (41% of adults and 32% of children) receive treatment. New HIV infections are down one-third in the last decade, from 3 to 2 million a year, but declines have slowed among adults.
We can dare to envision an end to the coverage gap and control of the HIV epidemic if we can successfully do four things: (i) sustain international HIV financing; (ii) increase domestic HIV financing; (iii) improve efficiency; and (iv) harness innovation in science and technology.  
What must we do to realize our vision of epidemic control?
First, we need to optimize the balance between international and domestic funding. BRICS and upper middle-income countries already largely pay their own way, freeing up vital international resources for others. Lower middle-income countries will continue to require international financing, but must pay a bigger share. The days when middle-income countries can finance less than 10% of their responses are behind us. The money freed up will allow development partners to continue to finance the lion’s share of HIV responses in high burden, low-income countries.
Second, we need to tap economic growth, expand overall health financing, and integrate AIDS services and financing into health systems and universal health coverage (UHC) benefits packages.
Several countries with large HIV epidemics have reduced the share of government budget allocated to health. This may have been a smart play when international health financing was soaring, but it’s no longer tenable. The World Bank Group’s initial analyses of indicative countries in East Africa suggest that, with projected 5% economic growth and an increase to 8-10% of the share of the national budget allocated to health, these countries can finance a benefits package that includes AIDS services. Integrating AIDS into UHC, and service delivery into health systems, will allow countries to offer universal services and enable major development partners such as PEPFAR and the Global Fund to turbo-charge national responses, to accelerate epidemic control.
Third, we need to harvest the gains of improved allocative efficiency. Approximately 40 World Bank Group Optima analyses suggest that we can rapidly increase allocative efficiency by 30% in concentrated epidemics, 20% in mixed epidemics and 10% in generalized epidemics. That’s akin to a 10-30% budget increase. Across numerous studies, we’ve found that we can improve allocative efficiency by increasing investments in three high-impact interventions: (i) AIDS treatment; (ii) male circumcision in Eastern and Southern Africa; and (iii) combination prevention for key populations, including sex workers, men-who-have-sex-with-men and people who inject drugs.
We can also improve implementation efficiency. Better geo-targeting, integration, procurement, logistics, task shifting, e-health, real-time data and performance contracting can give us another 20-30% in efficiency gains – and another effective budget increase of 20-30%. Preliminary PEPFAR analyses suggest that giving patients six months of AIDS drugs per visit and doing viral load testing annually may enable them to almost double the number of patients on treatment.
Fourth, we need to harness continued innovation in science and technology.
Innovations in delivery technology continue to accelerate and offer opportunities to rapidly improve implementation efficiency. The world’s largest HIV treatment facility, Themba Letu at Helen Joseph Hospital in Johannesburg, South Africa, had 30,000 patients enrolled before it decentralized services to clinics. It adapted a Vodacom “sorting robot,” which originally sorted cell phones and accessories, to sort and pack AIDS medicines and reduced pharmaceutical dispensing times from over 4 hours to approximately 30 minutes.
The same project is now piloting automated vending machines to dispense drugs, initially for HIV, but progressively for TB and for chronic diseases. Malawi is using technology to progressively extend the role of community health workers in HIV care. Social innovations such as Anti-retroviral Treatment (ART) Adherence Clubs (essentially patient groups who assign a member to collect medicines and distribute them to fellow patients) increase coverage and efficiency without compromising adherence.
In sum, the combined gains of sustained international and greater domestic financing and increased innovation and efficiency offer the tantalizing possibility there may be close to enough HIV money globally to achieve the ambitious goal of epidemic control.
How tragic it would be if this were the case, and we didn’t capitalize on it. Let this sobering reflection serve as a clarion call for an implementation revolution in the HIV response, in which we harvest all the gains of improved allocation, targeting, implementation, integration and simplification to realize the goal of epidemic control and the ultimate vision of an end to AIDS.
Follow the World Bank health team on Twitter: @WBG_Health
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David Wilson

Program Director, Health Nutrition and Population practice of the World Bank

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