The new, five-year strategy calls attention to addressing social and structural factors — such as stigma and discrimination, violence against women, and punitive laws criminalizing gay people — that are keeping high-risk populations from accessing services. At least 92 countries continue to criminalize HIV exposure, nondisclosure, and/or transmission, and 48 countries still block the entry of people or residence of people living with HIV, according to the strategy.
Failure to address them has held back the HIV response, advocates said.
“We desperately need a response strategy that tackles those difficult issues, and I would say that now for the first time we have a global AIDS strategy that really does that,” Fionnuala Murphy, head of influence at Frontline AIDS, told Devex.
“We know which approaches are most effective. Those are community-led approaches.”— Fionnuala Murphy, head of influence, Frontline AIDS
The strategy highlights the need to address inequalities in access to services — between and within countries and key populations most vulnerable to HIV infection. It brings the focus on community-centered approaches, the use of granular data to understand why and for whom the current response is not working, and calls for the reallocation of resources away from less-effective HIV prevention interventions. The strategy also puts an emphasis on the role of youth in the HIV response.
James Cole, advocacy officer for STOPAIDS, said that while the strategy had wide support, Russia voiced concerns that some of its recommendations, such as cold turkey approaches on drug use, weren’t included in the final strategy.
“But it’s difficult to see how some of their points could’ve been incorporated given the strategy’s commitment to evidence-informed approaches and advancing people’s human rights,” he said.
Advocates say the next challenge will be executing the strategy, but they hope governments at the U.N. High-Level Meeting on HIV and AIDS in June will back it and make financial commitments to ensure its successful implementation. They also hope governments would support the full replenishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria in 2022, as well as the Robert Carr Fund, which supports civil society and community networks.
The strategy is a “wake-up call” for the U.S. President's Emergency Plan For AIDS Relief and other donors that their investments are in line with science and human rights, and their funding matches the strategy’s ambitions, said Asia Russell, executive director of Health GAP, who called on the Biden administration to prioritize PEPFAR.
“It's been almost 100 days of this administration and up to now it has not appointed a qualified ambassador within the state department to lead this program,” she said.
Make HIV response work for all, not some
While HIV infections have declined among young women in many parts of the world, the risk of HIV infection among adolescent girls and young women in sub-Saharan Africa is still high. Men living with HIV are also less likely to access HIV testing and treatment than women living with HIV. And children are often left behind, according to the strategy.
A new guidance document seeks to "foster ethical, efficient, credible” and acceptable HIV prevention research but researchers say it may better serve an aspirational goal as it is currently unenforceable.
Only 53% of children living with HIV globally have access to treatment, according to the strategy. In addition, only 60% of HIV-exposed infants are tested for HIV at 2 months of age. While there have been reductions in the number of children acquiring HIV, there were still 150,000 new HIV infections among children in 2019, far from the global target of 20,000 by 2020.
Russell said highlighting the inequalities faced by children living with HIV is one of the big shifts in the new global AIDS strategy. Apart from low levels of treatment coverage, children also face delays in getting the results of their HIV tests, she said.
“Why does this matter? Because HIV in an HIV-positive child who's acquired the virus through gestation, delivery, or breastfeeding is terrifyingly fast-acting. So without access to treatment, more than 50% of kids will die before their second birthday. And in fact, HIV mortality peaks in this population in just a matter of months after delivery,” she said.
Many of the children living with HIV are also born to mothers or under the care of caregivers who are part of the key populations at high risk of getting HIV, but who similarly receive poor quality care, Russell said, who underscored the importance of addressing the needs of both children and their caregivers.
Use data to break barriers, inequalities
The 53% treatment coverage statistic for children living with HIV masks even lower rates of coverage in countries, Russell said. But the strategy’s proposal to use granular data could help address and unmask these poor services and access.
“This strategy will prevent heads of state from using epidemiology to game the system. Instead, it relies on disaggregation within communities, within countries, within regions so that the promise of 95-95-95 is actually … achieved for everyone, not just for some,” Russell said.
The ‘95-95-95’ refers to the 2030 treatment targets that aims for 95% of people living with HIV to know their status, 95% of people who know their status to be on treatment, and 95% of people on treatment to have suppressed viral loads. The strategy takes this a step further to ensure these targets are achieved within all subpopulations, geographic settings, and age groups, including children.
Data has always been a challenge in the HIV response, especially in countries where governments deny the existence of at-risk populations, such as gay people, men having sex with men, and people injecting drugs and their sex partners.
“Data is a very political topic in itself, and one of the things that we have tried to do as Frontline AIDS is to push back in contexts where we don't think that the government data is accurate,” Murphy said.
But Murphy also said having communities as part of data generation is crucial, and they should be part of governments’ decision-making processes, not an afterthought — especially as they’ve been on the frontlines of the HIV response for decades.
STOPAIDS’ Cole said community-led responses are often chronically underfunded in the HIV response, despite communities having been essential in campaigning governments and delivering HIV-related services.
Use resources for more effective HIV response
The new strategy calls for annual investments in HIV in low- and middle-income countries to reach $29 billion by 2025, and it breaks down where the money should be spent and why. But it also calls for a reallocation of about $1.15 billion, away from less-effective HIV prevention interventions.
The strategy doesn’t go into details of what these interventions are, but Murphy and Russell said they would include interventions such as billboard advertising on condom use and “abstinence only” messaging.
“We know which approaches are most effective. Those are community-led approaches where the people can get services in a safe way from people who understand them and don't discriminate against them … [but] those are the types of programs that we have to fight very hard to get funding for,” Murphy said.