A Step in the Right Direction
On June 25th 2015, the Lancet published online The UNAIDS – Lancet Commission on Defeating AIDS – Advancing Global Health, a detailed report by the Commission regarding a macro-strategic plan to defeat the HIV and AIDS epidemic by 2030 (http://www.thelancet.com/commissions/defeating-aids-advancing-global-health). The UNAIDS-Lancet Commission was formed in 2013 and Defeating AIDS represents the culmination of their work. The lead author and one of the co-chairs of the commission, Peter Piot of the London School Of Hygiene and Tropical Medicine, also serves on the Advisory Council for GAPW. The report differs from many other strategic plans in that it represents a macro-analysis of the lessons learned from the first three decades of AIDS and outlines several possibilities for its future.
Based on its analysis of the current state of the HIV epidemic, the Commission has created seven recommendations that serve as the backbone for the rest of the document. The recommendations are outlined in the box below:
These seven recommendations serve as pillars that structure the assessments, discussions, and goals throughout the document. This response to the Commission is divided into the five topics of funding, research, actors, human rights, and tailored responses as a way to simplify what the recommendations and the entire document offer in terms of defeating HIV and AIDS by the year 2030.
The report describes the lack of adequate funding as a primary hindrance preventing further progress against HIV, and argues that new approaches to funding the response to the epidemic must be considered. For purposes of this analysis, the report divides low-and-middle income countries into four epidemic categories: hyperendemic-settings, concentrated-(non IDU)-epidemics, IDU-epidemics, and generalized-epidemics. The document presents four separate economic scenarios with long-term projections to illustrate how innovative funding must be adopted: financial constraint (HIV response coverage is only expanded using the expected gross national income increases of each country, which resulted in the cheapest projection but had little immediate effect on AIDS deaths or new infections, and only marginal impact over time); best case (coverage in each country is expanded to match the best performing country in each category, which resulted in immediate decreases of new infections and AIDS deaths, but was the second most expensive model); global goals (projection where UNAIDS Fast Track targets are met, resulting in drastic immediate decreases in both infections and deaths but is by far the most expensive scenario); and current effort (a status quo projection which matches current trends in funding and HIV infection/AIDS death rates). This macro-consideration of finances is a departure from the often short-sighted terms found in HIV funding discourse, and the four diverse scenarios are useful in highlighting the critical role that increased HIV funding will have, both internationally and domestically, on the epidemic. In short, they show that no progress can be made without drastic changes in the current economic environment in order to ensure adequate funding for a sustainable response to the epidemic.
The report also makes a nuanced and compelling argument regarding the potential human capital that could be regained by proper HIV outreach, treatment, and prevention, postulating that lives saved are monies gained. It also proposes a shift from lower- and middle-income countries’ reliance on international funding towards sustainable, domestic economic developments that would allow them to contribute more effectively to their individual HIV responses. This is juxtaposed, however, with the economic data presented in section seven, as well as the financial-constraint scenario, which both show that low-income countries with the highest burden of HIV will not be able fund their programs via domestic growth alone. The specifics of how this shift would be realized and how to ensure effective economic regulation are not detailed in the report in any clear way. Further investigation on the actual steps needed to realize economic empowerment for developing countries with high HIV burdens is necessary.
Throughout the report HIV is framed as a societal issue, and as such, the authors point out that a biomedical response aimed at scaling up testing and treatment is not sufficient. With more people throughout the world gaining access to antiretroviral treatment, HIV has evolved from a fatal disease to a chronic one. This means that more relevant treatment, testing, prevention, and care methods need to be introduced and implemented. Among the methods suggested is socio-behavioral research. The report highlights that socio-behavioral research is needed in order to better understand the prevention and treatment needs of high-risk populations, and call for the development of better measures for social interventions. This point is key in that it advocates for a different form of evaluation than the often preferred randomized controlled trial (RCT), which is not always the most effective evaluation, particularly for these types of interventions.
Another approach that the report recommends increasing is implementation research, which is necessary to determine the efficiency and effectiveness of health systems and programs. This form of research is important in establishing whether an HIV intervention will have the appropriate effect on the population it is serving, and is critical in moving forward with smart and relevant initiatives. An inconsistency throughout the report, however, is the authors’ persistent push for Voluntary Medical Male Circumcision (VMMC). There is continuous debate regarding this method’s effectiveness, as well as the human rights issues the intervention presents. Missing from scientific data used to justify VMMC programs are the social and cultural implications of the intervention’s implementation: precisely the kinds of social and behavioral research findings that the report otherwise advocates for. The goal of implementation research is to determine what a randomized controlled trial cannot: how the intervention works in real communities. Evidence of pushback against VMMC can be found in research that has been carried out on various implementation efforts, calling into question whether VMMC should be advocated for as enthusiastically as it is throughout this report.
Regarding research coordination and funding, the report provides a number of excellent suggestions, including the creation of an UNAIDS HIV research desk, which would monitor and report on both public and private research, as well as funding, each year. This effort would be critical in ensuring that the appropriate research is being undertaken, that important research is not being overlooked, and that funding remains at adequate levels or greater.
The report gives special consideration, both supportive and critical, to all of the actors involved in the AIDS epidemic. Governments with previously strong responses are called out for the current complacency in their efforts against HIV, and the report acts as a “wake-up call” for political leadership that has begun to rely on HIV response methods that are superficial, ineffective, and outdated. Governments are accountable for governing their people, and the report denounces leaders who allow stigma and discrimination to stand in the way of national funding, which undermines efforts to combat the drivers that perpetuate the epidemic. The authors also highlight the need for activist and civil society initiatives to be reinvigorated through greater investment of resources and more linkages with other movements and sectors involved in health, gender equality, development, and human rights. The report, however, lacks specific proposals on how this can be achieved. It notes that in recent years activist efforts related to the epidemic appear to have been in decline, but offers little guidance in terms of specific mechanisms through which AIDS activism might be reinvigorated within the current conjuncture of social, political and economic circumstances.
Moving beyond civil society and activism, the report effectively emphasizes how the individuals living with HIV and key populations most at risk for the disease must be involved directly in these dialogues and structural shifts. Ultimately this report advocates for a multi-sectoral approach – from international bodies to those living with HIV, and everyone in between – to effectively combat the epidemic.
The report calls back to the early days of the AIDS epidemic when human rights were used as the focal point for prevention and treatment. The authors argue that the right to health must be brought back to the center of the AIDS response if we as a global community are to ever defeat HIV and AIDS. The article effectively integrates issues of stigma, discrimination, and criminalization into the topics of research, treatment access, key populations, and funding as a way to demonstrate that addressing human rights are essential to every aspect of the response. While human rights have been and will always be a key component to the AIDS response, the authors argue that we need to “refresh” our framework. This need is detailed in the current “micro-epidemics” that are unevenly distributed among different high-risk populations such as sex workers, MSM, transgender women and men, injecting drug users, prisoners, migrants, and females. Although these populations are different from the first decade of the response, the source is still the same: stigma, discrimination, violence and criminalization.
Importantly, the report argues that vulnerability to HIV infection among these populations cannot be solved with a simple biomedical approach. Rather, they require structural and social interventions to dismantle these social inequalities.
This point is crucial: human rights must remain the epicenter of the AIDS response if we are to truly succeed. But how? What remains to be said is the action to make people, governments, and society at large care for and support these high-risk populations. They are socially excluded, discriminated against and stigmatized strictly because of who society says they are, and it is no easy feat to change these deep-rooted perceptions. The report strongly and effectively argues for the importance of overcoming stigma and discrimination in the name of human rights and the right to health, but the real key is detailing how this can be achieved.
One of the report’s strongest points is the need for “tailored responses” to the epidemic. As stated earlier, HIV targets marginalized populations in society, which vary depending on the country, state, local context, and many other factors. Provided there is increased funding, innovative research, participation across sectors, and a human rights-based framework, the authors argue that the HIV response should be tailored to specific groups in their “local context.” As we have seen HIV to be a dynamic epidemic, it requires a dynamic response sensitive to the “disproportionate differences in HIV vulnerabilities.” Previous discussion about “key populations” defines these groups as separate or isolated from each other. This report illustrates the important reality that an individual can be classified under various key population groups, i.e. a trans sex-worker who injects drugs, all of which complicate the intricacies of relevant treatment, testing, prevention, and care methods. This point of diversity, complexity, and overlap of key populations is crucial to understand if we ever want to see the end of AIDS, and without a conscious commitment to tailored responses, all other efforts are moot.
The five major themes of funding, research, actors, human rights, and tailored responses are the strongest and most salient points present throughout the seven recommendations of the report and are vital if we truly seek to defeat AIDS. One of the key strengths of the report is its reiteration of these points and its clear demand for a sense of urgency in the AIDS response. The tone stands out from other recently published documents that increasingly portray the immanent end of HIV through positive sloganeering and empty promises of success. A wake-up call is indeed needed and this report provides a start. But it is only a start. More detailed and actionable steps are urgently needed to supplement this report in order to help activists, community organizations, governments, and private funders understand how to act. The report is extensive and shows great promise of moving towards a more dynamic, comprehensive and egalitarian response to HIV and AIDS. Defeating AIDS by 2030 is an ambitious goal by any standard, but we have everything to lose by not trying.