Michel Sidibé has a big job ahead of him. By 2020, the executive director of UNAIDS wants 90 percent of people living with HIV to know their status, 90 percent of people who know their status to access antiretroviral treatment, and 90 percent of people on treatment to have suppressed viral loads.
While achieving these 90-90-90 goals would set the world on course to end the AIDS epidemic by 2030 — in line with the Sustainable Development Goals — the reality is that only 51 percent of people know their status and of the 37 million people living with HIV, 17 million are on ART. As the 21st International AIDS Conference opens this week in Durban, South Africa, activists are calling for treatment for all.
Meanwhile, HIV infections among adults are not on the decline. In fact, infections are on the rise across some regions.
While there are promising new prevention tools such as pre-exposure prophylaxis, it’s not yet widely available in many settings, particularly for key populations.
And all this is happening while funding for response is on the decline, with more emphasis on countries most affected by HIV to finance their own responses, as many transition to middle-income country status.
Devex sat down with Sidibé at AIDS2016 to discuss the road ahead. Here are some highlights from that conversation:
UNAIDS has set the very ambitious 90-90-90 targets to be achieved by 2020. There’s 17 million people out of 37 million living with HIV on ART. What needs to be done to scale up people’s access to ART?
We have been ambitious because during the last five years we’ve been able to double the number of people put on treatment, which means that countries were not overwhelmed by the problem and they were able to define their strategy, to reach people and make sure that treatment was available. The biggest challenge I personally feel will be this one: the health systems. The huge number of people [receiving] treatment is [shedding] light on the inefficiencies of our health systems and the capacity of the health system to absorb and to be able to scale up quickly, more than they have been able to do.
If we don’t have a shift in the service delivery approach — to think about strengthening the community, reinforcing the interface between the last service provider and the community, and bringing civil society and others to become providers of services — it will be very difficult for us. That’s why I’m calling for 1 million community health workers to be implemented really quickly.
[Secondly], financing will be critical. What I’m seeing right now has scared me, if we continue to harbor the flattening and reduction of funding. We cannot lie to each other. I cannot see how Malawi, Zambia, even South Africa can get to 6 million people on treatment without any financial support. We need to continue to call for global solidarity. I think financing will be a key issue.
[Thirdly], how we will reach hard-to-reach people — those key populations who are today representing 35 percent of new infections? If we don’t have a strategy that can really quicken the pace and reach them and get them treatment services, then our ambitious goals will not be achieved.
A recent UNAIDS report found that new HIV infections among adults have stalled, failing to decline for at least five years. In eastern Europe and central Asia, new HIV infections rose by 57 percent between 2010 and 2015. What role do you think PrEP can play in HIV prevention and how can you expand its use among countries that are against it?
We are completely supportive of PrEP. We are working with countries to try and introduce PrEP in countries such as South Africa among sex workers. We are [also] trying to see how in Eastern Europe and Central Asia we can start pushing to make sure they can have the appropriate policy reform which can help them to target people who inject drugs so it can reduce infections. I think they are not closed to that [idea], even though we face the dilemma that we continue to believe that harm reduction programs should be put in place, that people should not be criminalized, and that people should not be facing prejudice and exclusion.
Even if with PrEP, if you cannot come for services, you cannot get the pill … that is the trade-off we need to manage properly — not just making sure that a pill becomes the magic response but restoring the dignity of people, making sure they are not hiding and not discriminated against. There’s a tendency to think that with PrEP pills will help us to resolve issues of infection. That’s true, but if you don’t reach people, if you have a series of bad laws that are not removed, it will be impossible for us to implement because the impact will be little.
There’s insufficient coverage of harm reduction programs across the globe and policies that criminalize people who inject drugs. The United Nations’ target to reduce HIV transmission among people who inject drugs by 50 percent by last year was missed. How can UNAIDS better advocate for harm reduction programs?
A good example is China: It was [previously] zero tolerance for people who inject drugs previously. What we did, was really bring the leadership of China to really understand the evidence — the science and the strategy information — coming from other countries. China today has the biggest harm reduction program in Asia. I think groups that are put on those programs are close to zero new infections. So it means that the pragmatic approach of China helped to completely change the face of the epidemic among drug users.
And there’s a lot of uncertainty around funding for AIDS response in the future. How will UNAIDS advocate for funding for key populations?
We are working closely with PEPFAR who in New York announced $100 million for key populations. I think it’s a catalytic fund and, for me, that’s what we need, to have the courage to say “these are targeted funds” [that] will help us to see how to better reach those people with a community network. I think it will certainly bring different modalities in the future —
how to finance those groups and how to support them — because until now they were part of a package of financing.
Having the courage to say that we have $100 million behind you and want to succeed, that really could completely change the way we can leverage [the funding] to scale up. We will see a lot of community groups who will start to be more vocal because they can get small amounts that help them to demonstrate that they can have an impact if they are given more resources.
Given that only 51 percent of people know their status, what role do think self-testing is going to play in the future? How can we increase its outreach?
I think we need to completely change our approach to testing. It’s good to go for routine testing and make sure that we make testing more convenient. Self-testing can therefore play a very important role, on one condition: we need to think about our service delivery approach. It’s not possible to have self-testing when you don’t have a different health system, which can be really big not on just the health system per se but a system for health. We need to think about systems for health — the community approach, so we have community health workers, a subsystem of health, which will be able to really deal with this self-testing [and] go door-to-door because they are trusted, have the capacity and are close. But, if not, we cannot tell people to go self-test ... It will fail completely because again we’ll have a lot of people who will test positive but will not have the ability to access services — they will be scared and they will not trust anyone.
What we need to think about in this period is how we electrify a different type of communication approach. Most young people are complacent. They don’t see people dying of AIDS. So we have a bulk of young people that need not just to be protected, but becoming actors of transformation in terms of prevention. That is, for me, a future challenge.
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