Where does the HIV/AIDS movement go from here?

SAN FRANCISCO — COVID-19 has disrupted the HIV/AIDS response, as it has done for so many other global health priorities. But the HIV/AIDS community wasn’t on track to hit its targets for 2020 even before the pandemic hit.

UNAIDS reported last week that the global HIV targets set for 2020 will not be met, and a new UNAIDS strategy will replace the targets outlined in 2014, which included the “90-90-90” agenda — 90% of people living with HIV knowing their HIV status, 90% of people who know their status on treatment, and 90% of people on treatment with suppressed viral loads.

As part of its new strategy for 2022 to 2026, UNAIDS is in the midst of a target setting process for 2025, when there will be just five years left to end the AIDS epidemic by 2030 as part of the Sustainable Development Goals.

At the AIDS 2020 conference, the U.N. AIDS agency shared updates on its plans and heard from activists, researchers, and policymakers about what steps the HIV/AIDS community must take in partnership with other sectors to turn gains into success.

Creating an enabling environment

While tremendous progress has been made on the 90-90-90 targets, stigma and discrimination stand in the way of reaching these goals.

Training health care providers on human rights and medical ethics, designing HIV services to be gender-responsive, and ensuring a supportive legal environment with access to justice can all help create a stronger enabling environment for HIV/AIDS interventions, according to Sherrie Kelly, an infectious disease modeler from the Burnet Institute in Australia who presented on the topic.

Shannon Hader, deputy executive director at UNAIDS, said the new UNAIDS strategy will include a greater focus on social enablers, addressing issues such as stigma and discrimination, gender-based violence, and criminalization.

At AIDS 2020, there were opportunities for activists, researchers, and policymakers to share their views on ways to incorporate learnings into the 2025 targets.

“It’s not that we don’t have the tools available, but it’s really about how do we use them effectively and optimally,” said Quarraisha Abdool Karim, associate scientific director of the Centre for the AIDS Programme of Research in South Africa. “We need to know the epidemic at a local level and then understand what are the drivers of new infections and the combination of interventions we have available that we can use.”

The U.S. President's Emergency Plan for AIDS Relief is adapting not only in response to COVID-19 but also in response to the reality of what is and is not working on the ground, according to representatives of the U.S. initiative.

“We know though that we have a tough road ahead of us. We know that there are extreme challenges for people living with HIV globally and they’re often exacerbated during COVID-19. It’s imperative that we prioritize a human rights approach centering on evidence and empowering and engaging the communities,” said Angeli Achrekar, principal deputy U.S. Global Aids Coordinator.

PEPFAR has worked to track patients on antiretroviral therapies, decentralize drug delivery, and use virtual platforms to communicate with people, as an increasing number of PEPFAR-supported countries make the shift toward multimonth dispensing, providing three to six month supplies of drugs in order to ensure continuity of care.

Several experts highlighted that multimonth dispensing is an example of a best practice that was recommended before the pandemic.

Countering complacency

The AIDS response is at a crossroads, said Peter Piot, director at the London School of Hygiene & Tropical Medicine and former UNAIDS executive director.

After spending his career fighting infectious diseases, he fell ill with COVID-19 in March, and addressed the AIDS 2020 audience from his home in London, where he is still recovering.

Piot outlined several areas for action that will determine whether the next decade sees greater progress against HIV/AIDS or millions of additional lives lost. He highlighted the need to rethink the narrative of HIV in light of COVID-19 and said the new UNAIDS strategy provides an opportunity to renovate the global AIDS strategy.

“Deaths from AIDS are not only a tragedy, but a scandal, because every death is preventable,” Piot said.

Piot called for renewed leadership that is unashamedly committed to AIDS. These leaders must be results-oriented, politically savvy, and effective in countering complacency, he said. Piot added that he wants to see more young people getting involved in HIV/AIDS advocacy, as they have done on climate change and racial justice, as well as closer collaboration between multilaterals.

He explained that as hard-won gains are at risk of being reversed, the future of HIV/AIDS funding is uncertain, so this renewed narrative must appeal to people in charge of budgets.

The world can’t afford for AIDS research to migrate to COVID-19 research, Pilot warned.

There is still a need to better understand transmission dynamics and design more effective programs, he said, also noting the threat of HIV drug resistance and the need for a vaccine.

Realizing universal health coverage

Dedicated HIV/AIDS funding and programming has been necessary to identify unmet needs, allocate resources, and track outcomes, said Eric Goosby, professor of medicine and director of global health delivery and diplomacy at the University of California, San Francisco’s Institute for Global Health Sciences.

“Siloed efforts are necessary,” he told Devex. “It is how much of my career has been framed, in an HIV or TB silo.”

But Goosby, who formerly led PEPFAR and is now the U.N. special envoy on tuberculosis, said it’s time to consider the needs of HIV infected patients in the context of their more comprehensive health care needs.

“To silo just their HIV needs becomes irrational and unethical,” he said.

The SDGs include ending AIDS as a public health threat and achieving universal health coverage by 2030. While the HIV response and the UHC effort can be complementary, there is also potential for tension between the two goals, Goosby noted.

While some experts at AIDS 2020 warned of the risks of resources from TB and HIV/AIDS being redirected to COVID-19, others said the pandemic serves as an important turning point to prioritize UHC.

“We need to sprint to universal health coverage,” Goosby said. “It is the only goal we should be really talking about at this stage in the game because we’re not going to fix the siloed diseases without a comprehensive health care delivery system around it.”