The end of the end of AIDS


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The recent Durban 2016 International AIDS Conference celebrates the success of AIDS treatment in reducing illness and death. The pall of despair and wasting death that hung over the Durban 2000 International AIDS Conference has truly been lifted. In KwaZulu-Natal, where the conference was held, AIDS treatment has increased community life expectancy by a full 11 years, reversing decades of decline -- life expectancy in KwaZulu-Natal is higher today than before the HIV epidemic. This is indubitably one of the great successes of global health.

However, the horizon is darkening, as the gathering storm grows starker. Unless we balance our celebration of the success of AIDS treatment with a sober appraisal of and rejoinder to these threats, we risk a reversal of painstaking gains.
The 2016 conference provides definitive evidence that international HIV financing has fallen from $8.6 billion in 2014 to $7.5 billion in 2015. Moreover, international financing is perilously reliant on one donor, the United States, which provides two-thirds of all international HIV financing -- broader, more diversified international and domestic financing would mitigate the risks of such concentration. 
Political commitment has waned and is moving from power to symbolism. We welcome the role that princes, princesses, film and rock stars played to raise the visibility of the conference, but we wish more heads of government, senior legislators, development and finance ministers had attended.
HIV incidence among adults remains tenaciously high. An independent IHME analysis shows new HIV infections leveling at 2.5 million annually - with 74 countries experiencing an increase in new infections. Even if HIV incidence were to stabilize, the absolute number of people with HIV would continue to increase, as the largest generation in history becomes exposed to the virus.

The Durban 2016 AIDS Conference marks the end of "ending the HIV epidemic" as a feasible goal with the tools we have. We need new and better tools. Talk of ending AIDS has led to a widespread perception in the broader health and development community that this crisis is over. It isn't and continued exhortations that we can end the AIDS epidemic with our existing armory may further undermine global recognition of and commitment to address this epidemic.

IHME, 2016

The 2016 conference also underscores the limitations of treatment-as-prevention (TASP - treating all for the public health benefit of reducing further transmission)) as a real world magic bullet to end this epidemic. In a cluster randomized trial in KwaZulu-Natal, TAsP did not reduce new HIV infections. In Botswana, Swaziland and South Africa, HIV incidence remains distressingly high, even as we approach or attain the ambitious 90-90-90 goal -- 90% of people with HIV knowing their status; 90% of people on sustained antiretroviral therapy; and 90% of people on therapy in viral suppression. Without decrying the transformative effects of treatment in reducing AIDS illness and death and slowing HIV transmission, we won't end this epidemic with tablets. We have never ended a global epidemic without a cure or vaccine and HIV is no exception.
We need to move beyond powerful advocacy messages to a remorseless focus on complex reality. 90-90-90 has been an effective rallying cry, but it's implied progression towards herd coverage and immunity does not capture the complexity of HIV transmission dynamics, which require us to first reach - and then retain - those with early, acute infection, high viral load and high rates of partner change or needle sharing - many of whom face multiple overlapping health and social vulnerabilities. We need a more targeted, nuanced, differentiated and comprehensive approach to epidemiological, implementation and social complexity.

What must we do better to navigate the gale winds before us?

We need to sustain international HIV financing – countries are not prepared for an abrupt transition. However, we must redouble our efforts to integrate HIV into the wider architecture of development assistance for health, an area where the Bank has a major role to play. We must focus on greater domestic financing and tackle displacement. Too many countries responded to increased global health financing by curbing domestic investment – this cannot continue. We must accelerate the progression from a short-term, emergency response to a sustained development response, where HIV is on-budget and integrated into national plans and budgets and universal health coverage (UHC) and health systems – also an area where the Bank has a key role. We need to sustain international commitment, while building national vehicles that will endure - the HIV response will be a long journey not a sprint. Ideally, international HIV support should provide the turbochargers and boosters of the global response, not the wheels and chassis.
We need to strengthen our focus on social and structural determinants of HIV transmission. Secondary education, income, greater economic opportunity and shared, inclusive growth reinforce HIV prevention – and are core Bank priorities. HIV prevention programs must also expand their focus on goals to include conjoined concerns, such as unplanned teenage pregnancies.
We must find new ways of reengaging heads of government and finance and development ministers, who may think the HIV crisis has ended and may not understand the long-term developmental and financial implications of an epidemic where new HIV infections remain stubbornly high and treatment costs rise inexorably. 
We must reconceive HIV prevention - there are no good outcomes without turning off the tap of new HIV infections.   We need to revitalize comprehensive prevention, including ART-based prevention, key population prevention and male circumcision in Eastern and Southern Africa, reinforced by wider education, social protection and structural interventions led by other sectors. There is no magic bullet but we do have a quiver of partially effective arrows, which if targeted, deployed and implemented at-scale together will slow new infections. As we embrace the undoubted promise of PREP, we must heed the lessons of TAsP and resist the false blandishments of a new magic bullet. We need more differentiated prevention implementation priorities that reflect HIV transmission dynamics - and concomitant implementation complexities and the realities of partial, uneven, mixed, variable and sometimes slow implementation. We also need to redouble our investment in new prevention technologies, including the vaginal ring, long-acting and implantable ARVs and above all a vaccine. 
The 2016 conference was mercifully free of the gloom of 16 years ago. Yet the mood was somber and purposeful as we confront a sobering truth. Advocacy outran science and created unrealistic expectations that we have the tools to end AIDS. In reality we face a long generational fight against a dogged virus.
We must revitalize international HIV commitment and financing alongside increased domestic financing, integrate HIV in national budgets and health systems, intensify comprehensive prevention interventions and research and redouble our focus on scaled implementation, grounded in the complexity of HIV transmission dynamics and the inherent messiness of real world operational challenges.
The remarkable success of AIDS treatment continues to buy time to implement comprehensive, scaled prevention and seek the new scientific tools we need to glimpse an ultimate end to AIDS - we must seize this opportunity with renewed urgency, purpose and apprehension of the enormity of the ground still uncovered.


David Wilson

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

Casper W Erichsen
August 10, 2016

You should come to Namibia where what you describe is basically the road map for how to reach our targets. The Minister of Health and First Lady, inter alia, are spearheading the effort to bring all stakeholders together, improve coordination, data collection, and allow for a more strategic response that accepts and works with the social complexities that impede us and keeps incidence stubbornly high. While trying to get to 90 90 90, which is essential, there is also a clear understanding that TaSP isn't the panacea it was billed as. One example of the national effort is the Minister of Health's instructions that the ministry write MoUs with CSO and private sector entities in areas of the response where the state cannot cope alone. He has also set aside 30% of HIV response budget for prevention, in a country where the state funds 67% of the total response.
Thank you for your blog and for stating what most of us know to be right, but few are openly saying.

David Wilson
August 10, 2016

We agree with your very thoughtful remarks. Namibia has a highly respected HIV response. We would note that Namibia appears to have fewer HIV incidence measurement studies than other countries with high HIV disease burdens. As a result, only modelled estimates of HIV incidence, with considerable uncertainty about actual HIV incidence, are available. Because of this, models that include a high protective effect for treatment-as-prevention (such as Spectrum) produce much lower incidence projections than the IHME estimates, for example.  
Namibia's comprehensive prevention approach is commendable - greater confidence about HIV incidence will help to evaluate the effectiveness of this major prevention investment.

August 17, 2016

TasP has been around since 1996, it just wasn't recognised until recently. The rates of HIV transmission and the caseload would have been much higher without treatments.

Casper Erichsen
August 12, 2016

Duly noted. We will put need for reliable incidence data on the agenda. When I asked PEPFAR about incidence data, they didn't have any and referred to UNAIDS data. So we are overly reliant on Spectrum.

David Wilson
August 17, 2016

We agree - and emphasize in the blog - that TAsP helps to slow HIV transmission. We do however argue that it and other existing tools are insufficient to end this epidemic.

May 23, 2019

PEPFAR is funding population HIV impact assessments (PHIA) in 19 countries in Africa. Incidence will be one of the very many pieces of information which come out of these national surveys powered for sub-national analysis. I think we will start seeing some changes in what comes out of spectrum once we have valid reliable numbers to plug into the model.

David Wilson
May 23, 2019

We fully agree and believe the PHIA surveys will greatly improve incidence measurement and reduce our dependence on modeled estimates. The surveys will enable us to better assess whether HIV prevention efforts are working in different sub-populations.

August 11, 2016

Much of what you say is true and I agree.
But your call for integrating HIV programs into health systems has the familiar tune of a developmental economist of World Bank!
We can't expect sex workers to collect condoms and people who inject drugs their needles and syringes from Government run health centres. Reason is too obvious to quote.
While progressive integration of biomedical interventions into health systems is feasible and desirable, prevention needs to remain as a highly focussed and fully financed and community run program which should remain a political priority.
Otherwise we keep lengthening the queue of HIV+ people waiting for treatment.It will be like chasing a moving target,

David Wilson
August 12, 2016

Hi Prasada
It’s always a pleasure to hear from you – we respect your work very much. We agree that some things – such as AIDS treatment are easier to integrate than others, such as HIV prevention for key populations. We also agree countries vary in their capacity to integrate activities such as harm reduction into health systems and this should always be considered. While recognizing both these considerations, it’s worth noting some countries have successfully integrated harm reduction into routine health care delivery systems – opioid substitution services in Australia and the UK are examples. Where we can do this, we think it helps to normalize services and reduce stigma. Where we can’t integrate immediately, we need to be pragmatic but we also can’t let health systems off the hook – they must become more socially inclusive too. We’re also worried HIV funding may gradually become orphaned unless we consciously seek to integrate HIV services. In short, your caution is well justified and I suspect our positions aren’t far apart!

Max Niggl
August 11, 2016

Thank you David for such an erudite discussion bringing us all back to the challenges we face to stop HIV.

David Wilson
August 12, 2016

Thanks for taking the trouble to comment. Australia's HIV response has been excellent and we've followed the recent debate about ending the epidemic in Australia with interest. Without reopening it, it does raise a globally important question about the level of resources required to sustain an effective response when HIV incidence becomes lower. We feel part of the answer is to make common cause with linked challenges, including blood borne viruses, sexual health and indigenous health. We're actually discussing these issues with AFAO now.

Dr Ngonidzashe Madidi
August 14, 2016

This is a very insightful article. The issue of domestic financing is critical for a response to be successful! Donor funding can only help initiate innovative designs but cannot sustain a full response. Zimbabwe had this well thought out at the beginning when the government introduced an AIDS levy to finance the response. It's a good move that would have translated to greater gains had we a high formal employment rate, the current tax base has undermined this noble initiate but the little that trickles through makes a huge difference.

Kiumbura Githinji
August 17, 2016

Thank you for your insight and suggestions which informs stakeholders in their concerted efforts not to drop the ball.
Considering the 90:90:90 approach, a thought came to me to add another 90 for those who are exposed using protective methods: 90 for integration into universal health and 90 for employment of local resources. The percentage can drop or rise to what is realistic but we should enjoin all other success factors into the model.

Patricia Linton-Forrest
August 18, 2016

An excellent analysis of the current situation. Welcome the challenges you present to all of us. Prevention through whole life education, in my opinion, remains one of our best options for reducing the occurrence of new infections. Thanks again for this thought provoking article

Dr.Rohan Suman
August 19, 2016

Excellent article.
We all know the said, but your writing opened the insight of the actual reality of the scenario.

Naphtaly Onyango
August 31, 2016

good move.we highly support your call fot the prioritization by various gvt.leaders and stake holders..The CBO N NGOS which atr in this fight should b supported fully.Finally..are there some chances if not posdibilities of totally treating this monster? If soon?
Viva la rasa.

Duane Crumb
September 10, 2016

Thank you for bringing the discussion back to the real world. As you wrote, "Unless we balance our celebration of the success of AIDS treatment with a sober appraisal of and rejoinder to these threats, we risk a reversal of painstaking gains."
However there is one obstacle to success that is not discussed in your article or most discussions at AIDS 2016 and other gatherings. The obstacle is the lack of infrastructure, especially in Sub Saharan Africa.
Even before we became aware of AIDS in 1981, there was a substantial shortage of trained medical personnel on the continent. Adding tens of millions of people living with HIV has dramatically exacerbated this shortage. Yet, we can't find anyone addressing the issue in any significant way. And this does not even address the need for more equipment for doing the necessary tests for following patients on treatment.
We talk a great deal about TAsP, Test and Treat, PREP, PEP, and other strategies showing such positive results in the West. However, it is totally unrealistic to propose these especially in rural African in settings until someone figures out a way to get more trained medical professionals to diagnose, prescribe, and follow these approaches.
When are we going to find this issue on the agenda for conferences like the recently completed AIDS 2016? Until we do, any talk of bring an end to the public health threat of HIV on the continent where more than 70% of the people living with HIV reside is irresponsible as it gives the world a totally unrealistic view of what can be accomplished.