A strategic revolution in HIV and global health

The Lancet, Volume 377, Issue 9783, Page 2055, 18 June 2011

Last week saw the conclusion of a landmark event in the recent history of AIDS. The two turning points took place in New York. The visible one was a high-level meeting on AIDS, which brought 3000 participants to the UN to review progress in defeating an epidemic 30 years into its devastating course.

Its mandate is to be bold, to say and do what others cannot say and do. The forthcoming UN General Assembly meeting in New York in September will be an opportunity for UNAIDS to unveil a potentially new leadership role in global health-one complementing but distinctive from that of WHO, one that puts AIDS at the leading edge of a new movement for integrating health responses to disease.

But it is UNAIDS, led by the politically astute and charismatic Michel Sidibé, that is perhaps in the best position to be a catalyst for integration. Unlike WHO, UNAIDS is not a member-state governed organisation. Indeed, UNAIDS was created precisely to fill gaps in the AIDS response left by countries, donors, and other UN and non-UN bodies.

This strategic revolution in global health poses important questions for AIDS governance. The Global Fund to fight AIDS, Tuberculosis, and Malaria is already reinventing itself slowly, but successfully, as a financing mechanism with a broader remit.

The total investment required to fund a set of basic programme activities, together with what Schwartländer and colleagues call “critical enablers” and “synergies with development sectors”, is US$16 ·6 billion this year, rising to $22 billion in 2015. PMTCT is only a very small proportion of that total: $0 ·9 billion this year, rising to $1 ·5 billion in 2015. Eliminating paediatric AIDS over the next 4-5 years is entirely possible-but only if AIDS is attacked as part of a comprehensive programme of interventions, from strengthening maternal health to scaling up family planning services.

This new approach will require new money. Bernhard Schwartländer and colleagues recently set out their vision for the resources needed to finance the next phase of the AIDS response. Solving AIDS will only happen if health systems are strengthened too.
If these successes were to be achieved, there will be fewer than 40 000 new paediatric infections in 2015, a 90% reduction.

New HIV infections in women aged 15-49 years will be reduced from 1 ·04 million in 2009 to 520 000 in 2015. Unmet need for family planning must fall from 11% in 2009 to zero in 2015. And HIV-associated maternal deaths will be cut from 21 000 to 2100 by 2015.  
Led by a coalition of UN agencies, global health initiatives, and civil society organisations, a new commitment was sealed last week-to eliminate paediatric HIV infections. The Global Task Team put together to deliver this goal is not isolating AIDS, as perhaps it might have done a few years ago. Their objective is to eliminate new paediatric HIV infections and, at the same time, to improve maternal, newborn, and child health in the context of HIV. The monitoring arrangements for tracking progress in HIV in children will embed this broader perspective. For example, one cannot address paediatric HIV without tackling HIV in women. The 2009 baseline of 1 ·4 million HIV-positive women delivering a child must be cut to 700 000 by 2015.

A good example of the new integration opportunity is AIDS in children. There are around 400 000 new childhood HIV infections each year. But in the 68 countries where most child deaths occur, coverage with antiretroviral treatment for prevention of mother-to-child transmission (PMTCT) of HIV is painfully low. The independent Countdown to 2015 group estimated that PMTCT coverage was only 22% in these countries in 2010.

Part of the reason for a change in strategy is a matter of brutal reality. Investment in AIDS is in decline relative to other spheres of global health. But the incredible success of the AIDS movement also means that it is in a strong position to embrace-warmly and generously-other sectors of global health. AIDS can be the engine that broadens a front to defeat the diseases of poverty.

But the invisible turning point was the realisation that simply strengthening the vertical programme that is AIDS has to end. The new opportunity is integration. As one senior UNAIDS scientist put it-AIDS is not an exceptional disease; it is an exceptional opportunity.

Ambitious new targets were agreed. Countries committed themselves to, by 2015: halving sexual transmission of HIV; halving HIV transmission among people who inject drugs; ensuring that no child will be born with HIV; getting 15 million people onto treatment; and halving deaths from tuberculosis among people living with AIDS.

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