When it started in the early 1980s, everyone was scared. No one knew how to help the people who were filling U.S. hospitals and then swiftly dying, or what to do for others suffering the same fate around the world. It was 1984 when one U.S. health official expressed hope for a vaccine within two years.
Now, over three decades and 39 million deaths later, we finally know how to treat, prevent and control HIV, although a vaccine remains elusive. But knowing is different from doing. The real challenge is scaling up what we’ve learned to stop new infections for good.
UNAIDS recently announced its new fast-track strategy to end the AIDS epidemic by 2030. “If the world does not rapidly scale up in the next five years, the epidemic is likely to spring back with a higher rate of new HIV infections than today,” officials from the U.N. agency said. That’s partly because half of the 35 million people who live with HIV today don’t know they’re HIV-positive, so they don’t know they’re in danger of passing the virus on to others.
By 2020, if the fast-track approach goes to plan, 90 percent of people who live with HIV will know their status, 90 percent of people who know they are HIV-positive will be on treatment, and 90 percent of people on treatment will have suppressed viral loads, making them less likely to transmit the virus. And by 2030, AIDS will no longer be a threat to our public health.
The goal is ambitious. There are still a lot of global problems and prejudices to overcome. But today experts can see what once seemed impossible — ending the epidemic — is finally within reach, and these five focus areas are going to help make it happen.
1. More health workers, ready for anything
Lab technicians, doctors, nurses, even the truck drivers who deliver antiretroviral therapies and other meds to clinics around the world are all health workers, and they’re at the heart of health and well-being in any community.
HIV demands all different types of health workers and skill sets, including palliative care, counseling, research, pharmacology and obstetrics, to name just a few. Pediatrics is another big one, as one of our greatest challenges ahead will be making sure all HIV-positive infants and children are on treatment.
According to the World Health Organization, we need some 7.2 million additional doctors, nurses and midwives worldwide. And unless we invest in the global health workforce, that number will grow to 12.9 million by 2035.
To end the AIDS epidemic, the world needs more health workers who are trained and ready to do the job, stationed in the right places, connected to the right technology, and safe from infection and violence. Countries also need to make better use of the health workers they have. Without health workers, we can’t test or treat even a single person — much less end an epidemic.
But it’s not just health workers’ skills the world needs. It’s also a commitment to equitable, unbiased health care for all.
2. Focus on key populations.
Members of key populations — something of a euphemism for sex workers, men who have sex with men, transgender people and injectable drug users — are marginalized and stigmatized. Their isolation and high-risk behaviors mean these groups have much higher HIV prevalence rates than others and they suffer the bulk of new infections.
Not so long ago, U.S. policy tried to prevent global health organizations from working with certain key populations. And when we did, we were often required to first document our moral indignation by proclaiming our opposition to, for example, prostitution.
Today this policy has changed. But that doesn’t mean that these key populations are getting the HIV services they need. Take Uganda’s infamous anti-homosexuality law — enacted and then repealed this year — which made it difficult for many to seek or even provide care without risking life in prison. Similar laws are still on the books in some countries.
Many members of key populations have been turned away by health workers. And many more have been socially outcast for so long that health care doesn’t even seem like an option anymore. So they fall through the cracks of health care systems around the world.
One example is in South Sudan. The HIV rate among the general population is relatively low, only 2.2 percent among adults. But among female sex workers — and there are many, particularly wherever there’s a strong military presence — the rates are much higher. The ongoing war and all its effects on the health system have turned the country into a tinderbox for potential HIV infections.
That’s why IntraHealth International, in partnership with the South Sudanese government, reaches out to sex workers at brothels and lodges, trains peer educators (that is, other active female sex workers), promotes and distributes condoms, provides testing and counseling for HIV and syphilis, and links women to other critical health services. Of the 546 sex workers we tested between July and September of this year, almost 32 percent were HIV-positive. Fortunately, most are now enrolled in treatment and getting the care they need.
3. Rock-solid health systems.
Over the past 35 years, we’ve seen what a strong health system can do to help countries respond to HIV. And in the past year, we’ve seen another virus, Ebola, spread out of control in West Africa. It’s clearer than ever that vulnerable health systems around the world have a long way to go.
Strong health systems are the bedrock of any healthy population. They lay a foundation built on governance, financing, technology, research, service delivery, and the health workforce (also known as human resources for health). To successfully address an epidemic such as HIV requires focus on each of these things, not just a few.
One way to make these systems stronger — and to lower rates of HIV — is to ensure systematic HIV testing and counseling. Integrating different types of services (HIV and tuberculosis, for example, or HIV and family planning) is a way to reach those at greatest risk.
Starting this year, a new USAID-funded global project called Linkages will play a big role in strengthening health systems around HIV. The project will build capacity within governments and civil society to offer high-quality HIV services that are sustainable, evidence-based, and comprehensive, specifically to key populations.
4. Strange bedfellows, unexpected results.
What do you get when you gather motorcycle taxi drivers, local traffic police, and a regional health management team in rural Tanzania? Hundreds of men and boys eager to lower their chances of contracting HIV and want to learn road safety tips all in one place.
It happened this year as part of a drive to offer voluntary medical male circumcision to men and boys in hard-to-reach areas. IntraHealth worked with the union of Kahama’s motorcycle taxi drivers to gather hundreds of community members together to offer the service, which lowers a man’s risk of contracting HIV through heterosexual intercourse by 60 percent.
Everyone had a great time, especially when a popular Tanzanian comedian showed up and talked about his own circumcision. And hundreds of men and boys opted for the procedure during the event.
Global health needs more strange bedfellows — that is, innovative partnerships — like these if we’re going to end the HIV epidemic.
5. ARVs to treat and prevent.
It was 2011 when U.S. scientist Myron Cohen and his team at the University of North Carolina at Chapel Hill discovered that treating HIV-positive patients with antiretroviral therapy while their immune systems are still strong significantly lowers their risk of transmitting the virus. His study proved the concept of treatment as prevention.
Today, some 13.6 million people (of the total 35 million who live with HIV) have access to antiretroviral therapy. We’ve come a long way. But the final push will mean making sure as many people who live with HIV as possible are taking these medications to reduce their viral loads — and their chances of transmitting the virus.
It will also mean honing our overall approach. Think community-based testing campaigns, provider-initiated testing and counseling, and even self-testing. But countries need health workers and strong health systems to support these approaches.
The new focus: key interventions that save lives.
“That’s because we know now that a generalized approach often doesn’t work,” Blyth explained. “In Uganda, for instance, new HIV infections are now rising, after dropping for 15 years. So from this point on, it’ll be about targeting the hotspots of the epidemic — reaching exactly the right people in the right places with the right treatment and services.”
The next 15 years are going to make global health history. They may mark the end of the most damaging epidemic in our lifetimes, during which countries around the world rallied together to face a unifying threat. Of course, these five approaches alone won’t be enough to bring this chapter to a close. But each one is vital to reaching our goal.
We’ve got just 15 years to make it happen. Let’s get to work.
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