What happens if there is no longer an exceptional AIDS response?

Long the exceptional disease, there is a growing recognition that donor funding for HIV is likely to fall in the coming years, raising questions about the sustainability of the global HIV response. Donors are pushing governments to increase support for their domestic HIV programs, but there is also an understanding that they will not fully replace donor assistance. That has left experts looking for models that will allow them to sustain the response, but likely with fewer funds. “We know that the time will come when the donor resources will dwindle,” Lloyd Mulenga, the director of infectious diseases in Zambia’s Ministry of Health, told Devex. “We have been preparing for that by trying to integrate.” He is not the only one. Countries and donors have long seen integration as central to facilitating this transition, but now the pressure is on to speed up those efforts. Rather than maintaining a vertical HIV program, with separate facilities, devices, and specialists, they want patients to be able to access multiple services during one visit. The idea is to cut costs and increase convenience for patients while maintaining quality HIV prevention and treatment services. Integration has its detractors, though, motivated by concerns that the quality of HIV services will decline, jeopardizing nearly two decades of investments and progress. And the communities that are most at risk of stigma and discrimination, including men who have sex with men, sex workers, and people who inject drugs, worry integration will bring about the closure of specialized HIV clinics. They fear they will face harassment from intolerant health workers in general facilities and, in places where sex work or homosexuality is illegal, possible recrimination. “You cannot choose to take a person, to go to a clinic that will criminalize your very existence,” Vuyiseka Dubula, a Global Fund official and long-time AIDS activist, warned during the recent International AIDS Conference. “People are going to die.” Though the theme of this year’s International AIDS Conference was “Put People First,” it would have made sense to assume it centered on sustainability since that was the issue that dominated the gathering. The news in early July that U.S. President Joe Biden’s administration was planning to cut the budget of the President’s Emergency Plan for AIDS Relief underscored the importance of the discussion. Michael Ruffner, the deputy coordinator for financial and programmatic sustainability at PEPFAR, was quick to caution during one panel appearance that the emphasis on sustainability “does not equate to the end of the PEPFAR program. We’re still going to have a robust program for some length of time.” Nevertheless, he said the program’s focus — the largest ever commitment by one country to fighting a single disease — was now to “close remaining gaps, maintain important gains, and find ways to handover elements of the response to our partner governments.” That’s emphasized by the sustainability road maps that PEPFAR has asked many of its partner countries to produce by December of this year. The purpose, according to the current PEPFAR strategic plan, is for country leaders to chart out “a specific set of milestones to transition country programs towards increasing leadership and management of the HIV response.” PEPFAR might not be going anywhere for a while, but there is a clear expectation that its role will shift, and governments will take more ownership of their domestic HIV response. And though the transition is not entirely about money, the people in charge of the effort say it does play a factor with vertical programs being expensive to maintain. That is why they are turning to integration. Rose Nyirenda, the director of Malawi’s national HIV response, told Devex there were some efficiencies her program could take advantage of, but “we need to sustain these gains and for that, also looking at the fiscal space right now, we want to have integrated platforms of care.” Where previously they would have a clinic exclusively for HIV patients, “you can still have a clinic, but you can also have the room where you are providing care to HIV patients also used for managing patients with [noncommunicable diseases], also managing patients with malaria,” she said. Nyirenda said donors have supported the beginning of the transition, which has required extensive efforts to identify potential gaps in systems, supplies, and training. “What everybody has realized is that with the integration, we will create savings that will be invested in other areas, other than HIV exceptionalism,” she said. But both she and Mulenga acknowledge that there are some services, particularly for key populations, where integration simply won’t work. “We have certain areas where they feel stigmatized and we are slowly building up the knowledge on being sensitive across all the networks, all the facilities in the country,” Mulenga said. But that will take time, and the country does not want to discourage anyone from seeking services as it pursues a process of integration. In the meantime, “we have identified certain hospitals or certain facilities which are sensitive to the needs of these populations who may feel stigmatized,” he said. Zambia criminalizes homosexuality and sex work, but Mulenga said they have tried to operate within the country’s legal framework to offer specific services to sex workers and men who have sex with men because health officials understand it is the only way to end Zambia’s HIV epidemic. In countries that are even more punitive toward key populations, it may depend on donors to fund the programs that provide services for these communities or risk decades of progress in combating the disease. For integration to succeed, Allyala Nandakumar, an economist at Brandeis University, agrees that there will have to be an intentional effort by all of the groups involved in the response to maintain — and extend — the equity that was gained in the vertical HIV programs. “What we are finding is that the equity of the HIV response tends to be better than the equity of the general health care system,” he said. And even within that response, there are still some communities that are being left behind, including key populations in some settings, but also people living in poverty and rural communities. As countries begin to shore up their health systems to prepare for integration, he said there may be an impulse to build out secondary and tertiary services. But that will further disadvantage some of the communities that are already struggling to access services. “We need to make equity core to the programming,” he said. “That is, we start by saying, what do we need to do to make sure that these populations are brought in.” He believes this can be achieved even with integration, but it will require innovative models where donors work with countries to incentivize equity. For some experts, the risks of integration — both the possibility of a general decline in services, but also of the possible interruption of services tailored to key populations — have them second-guessing the rush to transition. Instead of focusing on integration, “we should be accelerating to close those gaps that exist in the HIV response right now,” Angeli Achrekar, the deputy executive director of the Joint United Nations Programme on HIV/AIDS, said on a panel during the International AIDS Conference. She acknowledged that there are opportunities for integration, including many successful examples that already exist. But she did not want to see a fixation on integration undermine years or progress, particularly when many countries are still short of the 2025 UNAIDS targets for getting people tested and on treatment. “We need more than ever a coordinated, unified global solidarity around the HIV response and to continue the exceptionalism that we started until we finish what was begun,” she said. That doesn’t answer the question of whether the money will be there to make sure that can happen, though.