Position paper
UNAIDS recently released a 5 page Question and Answer document (http://www.unaids.org/sites/default/files/media_asset/2015_Implications_of_the_START_study_data_en.pdf) regarding the recent START Trial results which show that immediate antiretroviral treatment upon discovery of seroconversion (as opposed to waiting for an opportunistic infection or a low T-cell count) significantly improves health outcomes for those living with HIV. UNAIDS states that the START Trial results are in line with the organization’s ambitious target to end the HIV epidemic by 2030 with the 90-90-90 Fast Track plan. UNAIDS anticipates the integration of the START Trial results into its HIV strategic planning guidelines. The START Trial results were recently discussed in an earlier position piece on the Global AIDS Policy Watch website, which can be found here: http://gapwatch.org/news/articles/start-trial-demonstrates-importance-of-early-treatment-who-will-pay/474. The UNAIDS Q&A document discusses some critical issues and makes some positive contributions, but also has areas that require further consideration and follow-up.
An important aspect of the UNAIDS Q&A document is its emphasis on human rights. The document uses human rights as the framework to create informed decision making around treatment instead of the previously used “test and treat” method that violated the autonomy and rights of individual choice. This highlights the importance of ensuring that individuals are provided with information so that their decisions regarding treatment initiation are informed, and not coerced. It also addresses barriers that prevent access to services, such as punitive laws, violence, and harassment, emphasizing the importance of reducing the social barriers of stigma and discrimination that prevent access to health care and treatment for marginalized populations. It also highlights the role of civil society in providing human rights-based delivery of services. The Q&A additionally emphasizes the significant role that communities play in public health systems through reaching those who are least accessible in the health system and providing support. The need for “strong and resilient” healthcare and community systems is identified as the only way to provide optimal HIV services and care, while stressing the importance of the ability of low-income countries to negotiate for access or production of generic versions of drugs. Finally, in discussing the affordability of treatment, it focuses on the gain in human life rather than the more standard “cost-effectiveness” argument in terms of financial gains. It recognizes that even though money will always be an issue, saving lives must lie at the heart of responding to the epidemic.
While the UNAIDS Q&A document highlights many important human rights considerations of early ARV treatment, it also lacks clarity on some topics of discussion. Even in light of the limitations of a short, five-page publication, the document is quite cursory. Specific and diligent action must be taken to ensure that these equitable and ground-up implementation promises can be realized. For example, while the document calls for the integration of HIV treatment and services into strong and resilient healthcare systems, it does not discuss how weak or inadequate health care systems will be strengthened to achieve this. Additionally, financing earlier and increased access to HIV treatment must be innovative. The Q&A document focuses on the human capital that can be gained by the implementation of early treatment, but does not propose any strategy towards realizing it. Though most of the funding for low and middle-income countries will need to be covered by international donors, a specific and detailed action plan to do so is lacking, and this type of planning is crucial given the current plateau of international HIV funding.
The START Trial results provide an excellent opportunity to renew treatment access advocacy, but it is essential that governmental and intergovernmental agencies and policymakers go beyond advocacy. Real commitments need to be made to increase funding so that full implementation of the recommendations justified by the START Trial results can become a reality. Moving forward, it is important to balance enthusiasm with attainable goals and implementation plans. An increased emphasis should also be given to the important role of civil action groups and civil society involvement if goals are to be achieved as outlined. We must continue to consider the reality of lived HIV experiences globally and not get lost in “the end of AIDS” optimism that may obscure and underestimate what is still needed in order to adequately respond to an epidemic that is still out of control. Advocating for the end of AIDS is not the same as acting on it, and organizations like UNAIDS who have the power to influence policy need to use it to guarantee the concrete financial commitments that are still needed in order to stop the epidemic.