Ending AIDS begins with community engagement

The world's largest conference on a global health or development issue has just ended. The issue at hand was HIV and AIDS prevention. For decades, HIV/AIDS has been an urgent global challenge, and yet an event of this magnitude - dedicated solely to it - would have been unimaginable not long ago.

More than 18,000 delegates gathered together in Durban, South Africa, and the drive and determination to reach those who lack access to comprehensive HIV treatment, prevention, care and support services was immeasurable. The glaring question in today's fight against this heartbreaking disease is this - how do countries reach those who are still left behind, even now?

A similar question was raised sixteen years ago when Durban last hosted the International AIDS Conference. When we met then, the HIV epidemic was at a turning point. Access to antiretroviral treatment in the global north was turning HIV into a chronic disease while the lack of access to antiretroviral treatment in the global south was sentencing millions to death. The stark contrast between these two realities was the backdrop for what would be a historic gathering where activists, scientists and politicians pledged to address these inequities.

The Global Fund to Fight AIDS, TB, and Malaria was established the following year with the support of a cadre of new global health funders that contributed to an unprecedented increase in HIV/AIDS funding that would ensure people living with HIV in all parts of the world had access to antiretroviral therapy. A few years later, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the largest commitment by any nation to combat a single disease internationally, was also initiated.

The 2000 Durban conference prompted action, and since then great strides have been made in global health and the fight against HIV/AIDS. 17 million people around the world have received treatment and incidences in many of the hardest hit communities have declined. But there is still a great deal more to do. More than half the people living with HIV in the world do not know they have it because they have not been diagnosed, and 60% of people living with HIV/AIDS do not have access to treatment.

Yet the current goal is to end the AIDS epidemic by 2030 through fast tracking of what UNAIDS has termed the "90-90-90" target. The aim of this ambitious target is for 90% of all people living with HIV to know their status, 90% of all people with diagnosed HIV infection to receive antiretroviral therapy, and 90% of all people receiving antiretroviral therapy to have viral suppression by the deadline - four years from now.

These goals are achievable if we renew our commitment and invest in community-based service delivery models that target those who have thus far not received the necessary intervention - the people left behind.

In Ethiopia, for instance, a community-based approach has been crucial. We needed to decentralize HIV treatment. We understood that with 80% of the Ethiopian population living in hard-to-reach rural areas, addressing health challenges like HIV requires meeting people where they are. That all too common gap - between where the doctors, facilities and resources are based and where the individuals suffering from HIV live - had to be closed. This is what the Health Extension Program (HEP) was created to do.

HEP provides convenient and efficient local health services focusing on four areas: promotion of hygiene and environmental sanitation, prevention and control of major communicable diseases, promoting and providing family health services, and providing health education.

With the help of this program, along with intensified efforts to strengthen the health system, new HIV infections were reduced by 90% between 2001 and 2011. Between 2009 and 2012, mother-to-child transmission of HIV was reduced by 50% and AIDS-related mortality by more than 50%. 38,000 health extension workers, all women, have been trained to provide a basic package of these health intervention services.

This has brought about what's called the Health Development Army (HDA), an organized women's movement that communicates directly with families - promoting health practices and disease prevention across the country. The HDA mobilizes and empowers the communities to work with them to develop homegrown strategies for addressing local health challenges.

Made strong by the more than three million women in the program, the HDA has been successful in reaching those left behind by identifying critical obstacles and solutions to the delivery of healthcare services for each unique context. It has also created an integrated way of addressing related co-infections and conditions such as tuberculosis and non-communicable diseases.

The lesson we have learned from these reforms is that community engagement begets community engagement. The more we involve people in understanding their health needs and the accessible support available, the more likely they are to take action and pursue care.

This model can be replicated by countries facing similar challenges. More than 95% of people living with HIV are in developing countries where community engagement on these issues is often neglected. For true progress to be made, we must revise the approach to ensure inclusion of all communities and develop programs that enable health services to reach all citizens. Speaking from experience, this can be a complicated and daunting undertaking. It is an ambitious goal - but an achievable one. The fight against HIV/AIDS cannot be won unless countries take ownership of protecting and supporting the health of communities both near and far.

On its own, of course, community-based service delivery is not enough. Countries need to work in partnership with international agencies, donors, global experts, and one another in order to collectively end HIV/AIDS.

At present though, a thorough commitment to the community-level fight is the missing puzzle piece. If we work with communities, invest in local healthcare support and training, and enable the countries themselves - the ultimate experts in what will work for their communities - to lead those efforts, that 2030 goal will become more attainable.