Global health is filled with many ambitious goals and strategic plans. From increasing calls for countries to implement "universal health coverage (UHC)" to HIV-specific campaigns, such as Fast Track Cities and UNAIDS' 90-90-90 plan, there is no shortage of lofty goals with implementation plans to be accomplished. But questions remain as to how these different plans work alongside one another, and whether the targets are achievable in an environment where donor countries are shrinking their investments, in part due to a spirit of populist nationalism afoot in the U.S. and Western Europe.
Last week, more than 200 health care providers, researchers, and advocates gathered in Geneva, Switzerland, from across the globe to discuss progress and challenges in turning the tide on the HIV epidemic across the globe at the "Controlling the Epidemic" Summit organized by the International Association of Providers in AIDS Care (IAPAC). The summit addressed epidemiology and surveillance, metrics of success, preparing for new long-acting antivirals, biomedical prevention, social and structural drivers, and the state of the HIV workforce. Presenters represented global and multilateral institutions, implementing NGOs, and providers working at the national level.
Assessing Global Responses
The meeting began by looking at global trends in the epidemic and what's being done to address it from that perspective. Presenters in the first part of the meeting analyzed the health frameworks within the global response, including UHC, the sustainable development goals (SDG), and the 90-90-90 strategy, as well as the roles played by the World Health Organization, UNAIDS, and the U.S. Presidential Emergency Plan for AIDS Relief (PEPFAR) in framing and implementing these strategies.
"The theme of this meeting is the integration of the global response to the HIV epidemic as part of the larger response to global health, said Kenneth Mayer, M.D., summit co-chair and medical research director of the Fenway Institute in Boston. "Mantras like '3 by 5' are aspirational, and certainly 2020/2030 90-90-90 is aspirational, but I think a new realism has set in, in terms of an era of finite global resources, and the recognition that an adequate response to HIV has to include a response to primary care; it has to include sexual health; it has to integrate more with tuberculosis responses."
Related: The Usual Suspects: Common Challenges for End the Epidemic Planning and Implementation in Emerging Jurisdictions
Defining What We Mean By "Controlling" the Epidemic
Addressing the step before integration of HIV into a larger system of care, panelists first considered the question of what we mean by "controlling" the epidemic, and what metrics we use to measure success. Presenters also spoke to the need to address multiple variables in order to arrive at an AIDS-free world rather than using decreased incidence and reaching 90% viral suppression rates by 2020 as the sole targets.
Peter Ghys, director of strategic information and evaluation at UNAIDS, noted that the reduction of HIV incidence, as well as mortality, has to happen to achieve the goal of controlling/eliminating the epidemic. Moreover, prevention of new infections has to occur concurrently with ensuring that people with HIV live longer, healthier lives.
Prevention, in many ways, begins with HIV testing. A consensus seemed to exist among people from different parts of the world that, although our current methods of HIV testing have reached many, they still haven't reached enough people who are HIV positive but remain undiagnosed. While HIV rapid tests have helped to make testing faster and more widely available, people still avoid testing due to stigma.
Nitika Pant Pai, M.D., M.P.H., Ph.D, assistant professor of medicine at McGill University in Montreal, Canada, presented research on the use of HIV home-testing kits paired with a mobile app to connect people to counseling and referrals. Though one of the main critiques of home-based testing is the lack of counseling and linkage to care for people who are diagnosed, Pai's study (done with men who have sex with men in Canada and young people in South Africa), showed some success in reaching people who preferred the convenience and privacy of self-testing, and who did in fact get linked to care through the app if they were HIV positive.
But, beyond new models for testing, what are the possibilities for other developments in antiretroviral therapies and biomedical prevention? Carl Dieffenbach, Ph.D., director of the Division of AIDS in the National Institutes of Allergies and Infectious Diseases (NIAID) gave a presentation that looked at the challenges of development and implementation of long-acting antiretrovirals, but he also spoke to the need for new post-exposure prophylaxis (PEP) research and development. Right now, PEP consists of taking three medications (usually two pills) for 30 days, and the window from exposure to when PEP is most effective is very small. But it appears to be something that people really want.
"Something that we're seeing in our studies is the demand for PEP is surprisingly high," said Dieffenbach. "But there has been no innovation in the field of post-exposure prophylaxis for a very long time." He referenced a slide that suggested the need for the development of a single-dose PEP option.
Expanding Comprehensive Prevention
A huge focus of the meeting was delivery systems and the kind of HIV workforce needed to better meet the needs of patients. Presenters from different regions of the world presented some of the work happening to provide care to people with HIV and to increase comprehensive prevention, such as expanding the start of same-day antiretroviral treatment for people who are newly diagnosed. However, it was noted that, much as in the U.S., unsupportive government officials won't fund prevention and care services for key populations (sex workers, LGBT communities, drug users, prisoners) or persons for whom the cost of care keeps treatment out of reach.
A key group with among the higher rates of new HIV diagnoses around the world also has some of the worst outcomes along the care continuum: young people.
"We're trying to decrease new infections without treating the young people who may be transmitting the virus to each other," said Deborah Birx, M.D., ambassador with the Office of the Global AIDS Coordinator, who directs the U.S. PEPFAR program.
Focusing on Health Care Provider's Impact on Patient Adherence
Several attendees spoke to the need for providers and advocates to think about their approach to these discussions on "controlling the epidemic," and suggested a different name for next year's meeting that would be less stigmatizing for people living with HIV.
"For communities, even the language of 'epidemic control' is challenging, said Laurel Sprague, Ph.D., executive director of GNP+. "It starts to sound like controlling patients instead of controlling the epidemic."
But even Ambassador Birx called on health care providers to question not only their language but also the way in which they relate to the patients' challenges in getting tested, linked and retained in care, and virally suppressed.
"We should look at us first," she remarked. "Are we optimally providing the best services and care? And then we should look at issues like patient adherence."