While significant progress has been made, about 40 million people are still living with HIV worldwide, with 1-1.7 million new infections reported in 2023 alone. Many countries are working to achieve the UNAIDS 95-95-95 targets by 2025, which aim to ensure 95% of people living with HIV know their status, 95% of those diagnosed are on antiretroviral treatment, and 95% of those on treatment have suppressed viral loads. However, gaps in service delivery persist, particularly among underserved populations for whom access to HIV services remains limited and often fragmented.
Devex spoke with Edward Oladele, Ph.D., FHI 360’s technical director for HIV and primary health care integration, about how to address these gaps and ensure the sustainability of the HIV response. According to Oladele, there’s a need for stronger integration of HIV care into broader health systems in a way that addresses both HIV and larger health needs, particularly in underserved communities.
Since 1971, FHI 360 has focused on mobilizing research, resources, and networks so that people everywhere have the opportunity to lead healthy lives.
“The 95% target means reaching and diagnosing 95% of people living with HIV. What happens to the remaining 5%? Those are also my brothers, my sisters, my mothers, my daughters. Those are people, and we must have a system in place to continue to reach everyone,” he said.
As the global community marks World AIDS Day, Oladele told Devex how better coordination, sustainable financing, and community-led monitoring would ensure that the progress made in HIV care continues into the future.
This conversation has been edited for length and clarity.
What is the future of the HIV response as we approach 2025?
The future of the HIV response must become a comprehensive approach, one that integrates HIV services with existing health systems.
Let me paint a bit of a background to that response. When the HIV epidemic started, it overwhelmed health systems. Especially in the most affected countries. It was catastrophic: People were dying in unprecedented numbers, and the health system had no capacity to respond to that level of shock. When global HIV programs were designed, they had to rely on dedicated, parallel structures separate from routine health systems. And that’s the way HIV programs have continued to deliver HIV services in many places.
In the fight against HIV, we’ve made real progress with that structure. HIV-related deaths are down by 70% since their peak in 2004, and new infections in a single year are also down by about 60% from their peak in 1995 to what they were in 2023.
Now to continue this progress, HIV care needs to become a standard component of primary health care that is delivered to every person who comes in contact with the health system. What that means is delivering health care that is person-centered and context-tailored, because no two countries are the same.
Some countries have already achieved their 95-95-95 goals, and others are close. The system seems to be working, so why urge integration now?
Going back to that history — it was an emergency response. But we stemmed the tide. We now need to reshape the response for the long run. It's a classic case of “What got us here won’t get us there.”
In terms of why integration now, there are a few reasons. The 95-95-95 targets are supposed to be achieved by 2025, but what happens beyond 2025? That’s one of the critical reasons why we must talk about integration now. With an integrated approach, we’re able to expand access and improve coverage. And it’s an opportune time to pursue integration as we drive toward the global commitment to achieve universal health coverage by 2030. There is growing evidence to show that when HIV services and broader community health systems are integrated, client outcomes improve, and so do health system outcomes at large.
Additionally, as better treatments are available, HIV clients live longer, and they face other chronic communicable and noncommunicable diseases which require the involvement of other health departments. Integration will help to bring comprehensive services under one roof making it easier for the HIV client to access services for other diseases under one roof, saving time and resources.
Finally, the funding landscape is changing, and many countries remain heavily reliant on donor support for their HIV programs. In some countries, you will see a dichotomy: The HIV budget is 90% donor-funded and only 10% locally funded, while other health areas are 90% locally funded with minimal external support. It shows that making progress on HIV control is heavily reliant on donor funding. We need to support countries to build integrated and resilient health systems capable of sustaining and improving health outcomes regardless of changes in donor funding.
Will people who are most affected by the HIV epidemic get the same quality care in an integrated system?
The answer to that is an emphatic yes. Those who are most affected by HIV will receive the same quality of care, if not better, through an integrated system. But that won’t happen by accident. We must deliberately plan and work on it. And there are a number of things that must happen for integrated care to be delivered at that level of quality.
One, we must have trained health care providers. We must have sufficient numbers of health care providers, the right methods, the right working tools and supplies, the right infrastructure, diagnostic tests, and things like that.
Second, key populations, meaning those who are at high risk of HIV and most affected in many places, face stigma. They face discrimination and even violence, and they may avoid routine health systems. We must ensure when services are provided, they are in a place where people feel comfortable going. The same applies to priority populations like adolescents and young persons. So when integrating comprehensive services into community care, we must ensure the high quality of HIV services is maintained and not diminished by the addition of other services.
Third, monitoring of service delivery, feedback, and active engagement of the communities — all these things are essential for us to achieve quality services. If we’re integrating HIV services into existing routine health systems, we need to ensure we set standards — the right standards — with mechanisms for feedback to maintain a culture of quality.
When there is quality, people will use the service, because a positive experience encourages people to tell other people — and that contributes to strengthening the system and ensuring no one is left behind.
In areas with weak primary health care infrastructure, how can we ensure that integrating essential services into HIV platforms meets community needs effectively?
“Nothing about us without us” is a key principle in designing programs and services for all communities. Sometimes it sounds like a cliche, but it really is not.
Community engagement is fundamental to successful integration. It is one solid principle that ensures every aspect — planning, funding, implementation, and so on — meets identified community needs. This process begins with identifying those needs and involves communities in the planning, designing, and implementation. And engagement doesn’t stop there; communities must also be a part of monitoring received services and providing feedback. That’s what we call community-led monitoring. That feedback loop ensures that services continue to be responsive to community needs.
A key component of the feedback loop is a system of quality assurance and improvement. This includes addressing deficiencies, whether through building provider capacity or investing in infrastructure.
What challenges do you foresee in integrating HIV services into existing health systems, and how can these be addressed to ensure no one is left behind?
There are a number of challenges in integrating HIV services.
First, leadership and policy governance. Discussions on integrated services sometimes happen without involving the leaders of the health system itself, while poor coordination among implementers and donors — who may push conflicting agendas — further fragments health systems. So this process must be country-led from the start.
Resource constraints, such as limited human resources, funding, and infrastructure, can hinder integration — especially in rural and underserved areas. To ensure sustainable integration models, we need to have long-term financing in place.
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Additionally, we must find a way to mobilize resources from the private sector to complement public funds, and that also can be a key approach to stigma and discrimination. Integrating HIV into the existing health system can face resistance. It’s crucial to provide care in a non-stigmatizing, non-discriminatory environment, but that’s challenging.
Last, technical and operational issues, such as a lack of diagnostic tools, lab facilities, medication supply chains, and proper reporting, are also common obstacles.
If we want to address some of these challenges, we must support health systems in using data from the health system for decision-making, because that would help to target efforts to where they are most needed.
What’s your call to action for the global health community?
The call is straightforward: Now is the time. Now is the time for all of us in the global health community to rally together to strengthen the health system foundations for integrated person-centered, holistic care that leaves no one behind. And we need to ensure that people living with and most at risk of acquiring HIV are given the services they need, which means meeting people where they are.
Learn more about FHI 360’s work in HIV here.