by Adeeba Kamarulzaman, IAS President
Follow the science. That’s what we’ve come to know in four decades of responding to HIV, and that’s the message the IAS delivered at the fifth United Nations General Assembly High-Level Meeting (HLM) on HIV and AIDS in June 2012.
The response to the COVID-19 pandemic drew heavily on that 40-year HIV response to move at a pace never seen before, beginning to roll out a vaccine in barely a year. In turn, we in the HIV response must use that momentum to reinvigorate investment in research around crucial HIV knowledge gaps and ensure that data and evidence drive investments.
Let's be clear: HIV remains a critical global priority. Failing to reach the 2020 targets led to an additional 3.2 million people acquiring HIV since 2015 and the loss of another 1 million lives. Just in 2020, 1.5 million people acquired HIV, three times the 2020 target of 500,000 new infections, according to a Joint United Nations Programme on HIV/AIDS (UNAIDS) report, Global Commitments, Local Action, released on the eve of the HLM.
We know that social inequities remain a tragic driver of both the COVID-19 and HIV pandemics. UNAIDS estimates that tackling the HIV pandemic requires a US$3.1 billion investment by 2025. Its data show that the relative risk of HIV acquisition among female sex workers, gay and other men who have sex with men, transgender people and people who inject drugs is disproportionately high. In prisons and other closed settings, HIV prevalence is six times higher than in the general population.
In my region, Asia Pacific, UNAIDS data show that 98% of new HIV infections in 2019 were among key populations and their partners; this is against a global figure of 62% in 2019. To ensure that science informs policy and programme responses accordingly, we need investment in a robust, routine and disaggregated public health surveillance system. The evidence also clarifies that to respond duly, the resource needs in 2025 will be triple what resource availability was in 2019.
Specific areas in need of investment include:
- Research and innovation in vaccine development, progress towards an HIV cure, and evaluating models of service delivery
- Prevention tailored to communities’ needs
- Service delivery, including those led by communities, that responds to the diverse and dynamic realities of lived experience
- Advocacy efforts to improve policies for removing stigma, punitive laws and other structural barriers
- Robust evidence that includes community-led research to better inform policies, practices and innovations.
It is commendable that domestic investments in HIV responses in low- and middle-income countries (LMICs) have grown by 50% since 2010. Donor support increased by 7% in the same period. More is needed. According to Global Commitments, Local Action, reaching the 2025 targets set by the UNAIDS Global AIDS Strategy will bring comprehensive HIV services to 95% of the people who need them and reduce annual HIV infections to fewer than 370,000 and AIDS-related deaths from 690,000 to fewer than 250,000. The strategy emphasizes health equity, universal health coverage, innovation and ambitious targets.
Translating these individual and public health gains into economic terms, each additional US$1 of investment in implementing the strategy in LMICs brings a return of more than US$7 in health benefits. “The families and communities affected by HIV already understand that long and healthy lives are simply priceless,” the report says.
To meet the strategy objectives, we must double annual spending on primary HIV prevention from 2019 expenditures. Governments cannot afford to pick and choose aspects without following the science and evidence. And we cannot afford to under-invest, whether financially or politically, if we are to respond effectively to HIV.
However, investments will be wasted unless we remove criminalization and other laws and policies fuelling marginalization, discrimination, stigma and social exclusion. Such laws and policies further fuel social inequities that drive HIV transmission, delay or disallow access to services, and result in preventable deaths. We are obliged to act on the evidence.
Shortcomings fuel needs
The shortcomings of the past – and the resulting numbers of people in need of services – has increased the need for financial resources. The bill for the HIV response will keep climbing if commitments, funding and action continue to fall short.
How can we find these resources?
- Smart, evidence-informed programming that makes the best use of the resources available
- Improved cost efficiency by prioritizing and strengthening prevention
- Human rights-based policies that will achieve health for all and remove structural inequities driving ill-health
- Innovative domestic and global financing mechanisms.
In other words, follow the science.
We have to implement the Global AIDS Strategy and that requires adequate resourcing. Scientists and community leaders must be an integral part of the policy-making process on this mission. Over the past 40 years, the most remarkable victories have not been from HIV scientific breakthroughs alone, but from forming a common front that united scientists, activists, communities and policy makers.