Ted Eytan

What can we do now to end the HIV-AIDS epidemic?

By Vishnu Shankar (Stanford University)

With over 36.9 million individuals globally living with HIV-AIDS and an estimated 35 million people dead since the start of the epidemic, what will it take to have an AIDS-free generation? Last month, the United Nations announced their ambitious goal to end the HIV-AIDS epidemic by 2030. It has been suggested that these efforts will require greater money and political will in the most vulnerable countries, along with active efforts to strengthen health systems in order to improve patient access to care. This leads to a greater question with a less clear answer: what can we do in the immediate future with our existing efforts to end the epidemic by 2030?

With the upcoming Presidential elections in the United States and the House currently considering appropriations measures for previous governmental health policy, one successful policy that we need to increase the budget for is the President’s Emergency Plan for AIDS Relief (PEPFAR).

By most accounts, PEPFAR has been quite effective and one of the largest programs in global health targeting one disease by any nation in the world. Over the last few years, PEPFAR has provided anti-retroviral therapy (ART), the most effective therapy against HIV-AIDS, to 6.7 million people worldwide. For more than 1.5 million pregnant women, PEPFAR has prevented the transmission of HIV from mothers to children by providing them with ART. Early ART undoubtedly slows the progression of HIV-AIDS and reduces individual risk of mortality as well as spread of infection, thereby enabling even the most vulnerable individuals infected with HIV to live healthy, long, productive lives while preventing new cases from developing.

Further, epidemiological evidence from Dr. Eran Bendavid and his colleagues at Stanford University has shown “robust evidence” of the association between PEPFAR and reduction in all-cause mortality in African countries with the most intensive interventions that the program funds. Therefore, it is rather jeopardizing that PEPFAR, one of the most impactful US government-driven global health programs, continues to see large cuts in the proposed fiscal year 2017 budget. Since 2010, PEPFAR funding has declined by nearly 325 million dollars, including a 288 million dollar cut in the budget just last year.

If we truly aim to have an AIDS-free generation by 2030, it is crucial that U.S. senators and representatives act now in the upcoming budget process to allocate 4.845 billion dollars, the amount needed to capitalize on our previous investments in AIDS. In a recent article published in Health Policy and Planning, it was shown this investment will be crucial for countries with especially high prevalence of HIV-AIDS such as South Africa, where there is a need to re-allocate funding and integrate new services while strengthening local health systems. According to a report in April 2016 from Doctors Without Borders, some of this funding needs to be allocated specifically to scale up HIV testing by increasing the number of sites that offer free testing and counseling, strengthening a patient-focused network of HIV services between “civil society, patient associations, faith-based organizations (FBO) and NGOs that facilitate referral and linkage to care,” and ensuring sufficient availability of ARTs by supporting community-based refill initiatives and peer support.

However, increasing the bilateral funding through PEPFAR for improving treatment coverage and strengthening the patient-network is not enough. To end the epidemic will also require a shift in the way we view prevention strategies for HIV-AIDS.

In 1985, when Dr. Don Francis, Director for the Center for Disease Control AIDS Laboratory Activities, prepared the first national HIV-AIDS prevention plan for 20 million dollars, he was denied funding by Congress, as they did not perceive HIV-AIDS to be a credible global threat. It was apparent that the lack of any early investment in a HIV-AIDS vaccine research or prevention program has had drastic consequences. As the epidemic was only nationally acknowledged in 1987, by which time more than 50,000 cases of AIDS had been diagnosed, the government’s early investment would have averted the current well-identified need for investment in HIV-AIDS vaccine development, better prevention strategies, improved treatment coverage, and greater treatment options.

The current efforts towards fostering an HIV-AIDS free generation have primarily focused on “treatment as prevention” paradigms. Ending the HIV-AIDS epidemic will require a paradigm shift, one that shifts our efforts to protecting populations rather than only investing in treating HIV-AIDS positive patients. According to Dr. Thomas R. Frieden, current director for the Center for Disease Control, HIV needs to be fought “how syphilis and gonorrhea are fought”, by protecting the population at-large rather than targeting individual patients alone. Most government investment in HIV-AIDS focuses much of its efforts on research and treatment, often overlooking the need for investing in development of a vaccine. As Dr. Paul Farmer, co-founder of Partners In Health, indicated to me, PEPFAR has been instrumental in this movement towards global health equity. As Partners in Health has worked in building sustainable health systems to protect the most vulnerable populations, Dr. Farmer explained that PEPFAR has “brought critical new resources and attention to the fight” against AIDS, thereby “enabling life-saving care for those long shut out of modern medicine.” Even more, he expressed that our battle against AIDS has been the symbolic “catalyst” in our broader “movement for global health equity.”

Therefore, for us to end the epidemic will not only require “predictability in funding flows […and…] resilience in leadership,” as Peter Piot, Director of Global Health for the London School of Hygiene & Tropical Medicine puts it. It will also require integrating new prevention methods in the existing patient-focused network along with a steady focus on strengthening health systems, thereby improving treatment access and coverage. Most importantly, we need the “courage to press ahead, because if we fail the challenge of HIV prevention, HIV-AIDS will relentlessly undermine human progress.” We are in a now or never situation and need to act today to replenish the funding for PEPFAR if we are to end the HIV-AIDS epidemic rather than continuing to tread water in our fight against the disease.

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Vishnu Shankar is a sophomore at Stanford University, studying chemistry, mathematics, and computer science. He is the advocacy lead for Partners In Health Engage, where he works with local Congressmen and his peers at Stanford to illuminate issues surrounding health policy.

Image credit: Ted Eytan

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