World AIDS Day: a time for celebration of successes and renewed commitment to unresolved challenges

This blog, by Anthony Kinghorn, originally appeared on the Oxford Policy Management website, and is reposted with their permission.

World AIDS Day is a time to celebrate successes in tackling the HIV/AIDS epidemic. The global response has achieved reductions in the numbers of AIDS deaths and of new infections which we might once have thought impossible. Globally, over 20 million people are receiving antiretroviral therapy (ART) and the annual number of AIDS deaths has halved from around two million in 2004 to one million in 2017. The number of new infections has dropped from three million in 1997 to under 1.5 million in 2018.

However, it is also a day to recognise that huge numbers of people are still dying and becoming infected with HIV. So, while the potential to end AIDS as a public health emergency is there, achieving that will still take concerted effort and resource allocation.

Central to success will be the achievement of the goals of the 90-90-90 Fast Track strategy and the 2016 Political Declaration on HIV. These aim for high levels of HIV testing, antiretroviral treatment access, and successful viral suppression, as well as intensified HIV prevention, underpinned by elimination of stigma and discrimination affecting people affected by HIV.

Some regions and countries face particular challenges. In western and central Africa only around 40% of people living with HIV/AIDS (PLWHA) are aware of their status, compared to 70% or more in most other regions. In eastern Europe and central Asia, an estimated 70% of PLWHA know their status but less than half of those are on treatment. By comparison, in eastern and southern Africa, around 80% of PLWHA know their status and around 75% of those are on treatment.

Supporting progress towards ending AIDS as a public health emergency: some priority challenges

Achieving ambitious global and country targets requires countries to scale up existing interventions to achieve scale. But progressing the next few percent towards targets increasingly requires innovations. These need to fine tune standard interventions, and also to supplement them with new models that can serve harder-to-reach populations and address more challenging risks and needs. In addition, responses need to use available resources more efficiently to ensure efficiency, affordability, and sustainability within available resources.

OPM has for some time been supporting the HIV and AIDS response. This has included its work on many aspects of strengthening health systems and improving financing for health care. In addition, OPM has worked in key areas such as financing options for HIV responses and health, and improving efficiency of the HIV response and services.

In OPM’s current work, several challenges to controlling the epidemic and its effects are prominent.

Transitions from donor funding and ensuring financial and programmatic sustainability

In the current funding environment, particularly in countries transitioning from Global Fund support, countries need to investigate and start developing customised, evidence-based sustainability roadmaps and plans with stakeholder agreement. A number of countries are engaging in National AIDS Spending Assessments, investment cases, and costings and efficiency analyses to define resource requirements and more efficient ways of using available resources. However, best practices in planning for transitions and sustainability are still being established.

Customised responses to address regional, national and community needs

Achievement of targets is particularly difficult in certain contexts and customised approaches are required. Innovative, differentiated models for delivery of services to communities must deal with financial and capacity constraints and make service more accessible.

Challenges to scale up in west and central Africa are a particular concern in current work to support the regional catch-up plan. New understanding of epidemics in the region, as well as new evidence on the effective models and approaches and targeting of interventions in responding to the epidemic, have been emerging, and can accelerate impact of responses. Consideration is being given to analysing bottlenecks, implementing new more accessible models for service delivery, and potential to enhance the role of civil society to deliver services and deal with issues such as barriers related to stigma and discrimination.

Continuing to improve the impact of Global Fund Grants

The Global Fund (GF) is a critical contributor of resources for achieving Political Declaration and 90-90-90 targets. Maximising the impact of those resources often requires support to help country-level implementers to overcome bottlenecks, including stigma and legal barriers to services effectiveness, and improving management systems and capacity of implementers. Strong monitoring and evaluation, and effective use of strategic information is required to track impact of GF-supported programmes on fast-track targets, to inform both management and planning to expand effective delivery models for greatest impact, and to ensure more effective responses to key populations.

Consolidating HIV prevention

The number of HIV-infected people who need care and treatment continues to accumulate. The Global Coalition on HIV Prevention has emphasised the need for greater momentum and strategic investment in HIV prevention. This will require more effective coverage of proven, effective interventions including condoms, circumcision, ART, prevention of mother-to-child transmission, and harm reduction. But ending AIDS will also require a combination of these with enhanced intervention models, and innovations such as PrEP, to provide people with a menu of options which responds to their diverse needs and risks.

UNAIDS has launched a Technical Support Mechanism (TSM) to provide quality technical support to assist its partners at country, regional and global levels to achieve priority HIV programme results. OPM has been appointed to manage the Technical Support Mechanism for UNAIDS. You can read more about it in our dedicated project page.

The UNAIDS TSM is focusing on assisting countries to maximize impact of financial support from the Global Fund (GF), in line with the Fast-Track Strategy and the Political Declaration on HIV (2016). The UNAIDS TSM has a primary focus on three regions eastern and southern Africa (ESA), Asia Pacific (AP) and western and central Africa (WCA),