By Heather Johnston and James Orbinski, Dignitas International
On December 1, we marked another World AIDS Day in the global fight against the epidemic.
As a result of key investments over the past two decades, primarily through the leadership of the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), millions of deaths and new infections have been averted.
According to the Center for Strategic and International Studies, of the 120 billion USD invested globally for HIV programs to date, more than 72 billion USD came through PEPFAR. Last year alone, with a PEPFAR investment of 6.8 million USD, the U.S. government supported a range of HIV programs including testing and counselling for 74.3 million people and treatment for 11.5 million people.
Through a sustained effort, HIV-related deaths have fallen by 48% since its peak in 2005 and today nearly 21 million people worldwide are on lifesaving antiretroviral treatment. Treatment not only enables a person living with HIV to regain their health, but it also prevents transmission of the virus to others. A universal 'test and treat' strategy is the key to ending the epidemic.
However, while the path to an AIDS-free generation is clear, it is no longer certain.
This past September, the U.S. State Department released PEPFAR's new Strategy for Accelerating HIV/AIDS Epidemic Control. The vision of this strategy is to accelerate progress towards epidemic control in 13 high-burden African countries. The "lucky 13" – Botswana, Côte d'Ivoire, Haiti, Kenya, Lesotho, Malawi, Namibia, Rwanda, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe – have apparently been selected to receive funding because of past achievements in reducing HIV infections and AIDS-related deaths and their potential ability to control the epidemic by 2020.
However, coupled with this new strategy is significant uncertainty around the level of HIV investment. For its 2018 budget request, the Trump administration has proposed a $1.1 billion reduction in international HIV programs. It is entirely possible that Congress will deny these cuts, but without an approved U.S. budget, the future of PEPFAR remains unclear.
For the last 13 years, Dignitas International, a Canadian medical and research NGO, has been delivering HIV programs in Malawi – a country once ravaged by the epidemic. As a recipient of PEPFAR funding since 2010, Dignitas provides HIV treatment and care in partnership with the Malawi Ministry of Health and mentors frontline health workers to do the same for more than 3.6 million people in southern Malawi. We have witnessed how U.S. investments have transformed the delivery of HIV care and saved countless lives in the process.
A powerful example came just a few years ago. In 2011, informed by research conducted by Dignitas and others, Malawi was the first low-income country to adopt an ambitious strategy to prevent the transmission of HIV from mothers to their babies. Nearly 150,000 infants acquire HIV from their mothers annually around the world.
Known as Option B+, this program offers HIV testing and lifelong treatment to all pregnant women, regardless of the stage of their disease. By suppressing an HIV+ mother's viral load with antiretroviral drugs, Option B+ prevents transmission to her baby before and during birth, and while breastfeeding. This ensures that babies are born HIV-free and that mothers remain healthy so they can care for their children. Along with other organizations, Dignitas played an important role in influencing this national policy decision in Malawi and in training frontline health workers to deliver the treatment regimen.
This policy change has had an incredible impact – early results from a U.S. government funded national evaluation of Malawi's Option B+ program has shown that women not on HIV treatment during pregnancy are 10 times more likely to transmit the virus to their child than women on treatment.
Following Malawi's pioneering step, the World Health Organization endorsed Option B+ in 2012 and more than 20 countries have since adopted it as part of their HIV prevention strategy. This is a strong return on investment with U.S. dollars invested in one program and in one country having a transformative impact around the world.
In 2015, UNAIDS, along with PEPFAR and others, launched a fast-track approach to end AIDS by 2030. The approach aims to achieve key targets such as fewer than 500,000 people newly infected with HIV; fewer than 500,000 people dying from AIDS-related illnesses; and eliminating HIV-related discrimination.
At the end of 2016, $19.1 billion was available for the AIDS response in low- and middle-income countries. To achieve fast-track targets, AIDS funding would need to grow to 26.2 billion USD in 2020 in low- and middle-income countries. After this peak, resource needs would decrease annually to 23.8 billion USD in 2030.
UNAIDS has already warned that even taking a business-as-usual approach and maintaining current HIV spending in low- and middle-income countries would cause a dramatic rise in AIDS-related deaths. It is irrational to expect that low-income countries will be able to achieve the fast-track targets with fewer resources.
The desire to focus investment efforts on the 13 high-burden countries close to epidemic control shouldn't come at the cost of the other 50 PEPFAR countries that continue to struggle with the epidemic. Budget cuts threaten to derail the success in reducing AIDS-related deaths and new infections since PEPFAR launched 14 years ago. Such cuts are not only counterproductive; they could initiate an epidemic rebound.
Rather than cut funding, we need a more responsive investment model. If the U.S. is committed to demonstrating impact for every dollar spent, it must revisit its Strategy for Accelerating HIV/AIDS Epidemic Control – both from an investment and implementation perspective.
But the responsibility to end AIDS does not rest alone with the United States. Canada and other G-20 countries must also step up their commitments to achieving an AIDS-free generation. The path to ending AIDS is clear: we must stay the course. The lives of millions depend on it.
Heather Johnston, President and CEO, Dignitas International
James Orbinski, Co-Founder, Dignitas International; Director, Dahdaleh Institute for Global Health Research, York University Professor, Faculty of Health, School of Health Policy & Management, York University; Professor, Dalla Lana School of Public Health, University of Toronto
This blog is part of the blog series: Barometer Rising: No time to backtrack the fast track to ending HIV as a global health threat by 2030 by the Interagency Coalition on AIDS and Development (ICAD) in recognition of World AIDS Day (1 December). The series features a selection of blogs written by our member and partner organizations. Contributors share their broad range of perspectives and insight on the right to health within Canada and globally to critically reflect on the response to HIV knowing we are now just 2 years from the 2020 Fast-Track targets (90-90-90) and just over a decade away from the 2030 Global Goals for Sustainable Development (SDGs).
Are we on the right track or are we on the back-track?
Disclaimer: The views and opinions expressed in this blog series are those of the authors and do not necessarily reflect those of ICAD.