At the IAPAC summit, Douglas Shaffer, Chief
Medical Officer of the Office of the US Global AIDS Coordinator, said that we
have “about a five-year window” to reverse the projected increases in HIV
prevalence.
He offered up Uganda, an
early-indicator country in Africa ever since the start of the epidemic, as an
example of what could begin to happen from now on. In most African countries
there has been a tight correlation in the 2000-2014 period between falls in AIDS-related
deaths and falls in new infections. For instance, a recent fall of 30% in AIDS
deaths in the Democratic Republic of the Congo has been accompanied by a 33% fall
in new infections. In neighbouring Rwanda, an 80% fall in AIDS deaths has been
accompanied by a 60% fall in new diagnoses. Even South Africa, with its huge
HIV problem, saw a 40% fall in new diagnoses in this period.
But in Uganda, a 65% fall in AIDS deaths
has been accompanied by a 40% increase
in HIV infections. Uganda is accompanied by countries that tackled their
epidemics much later such as Nigeria, which saw a 35% rise in diagnoses last
year.
Shaffer put this in the context of the
global standstill in HIV funding: the joint contribution to HIV of the US
PEPFAR (President’s Executive Plan for AIDS Relief) programme and the Global
Fund for AIDS, Tuberculosis and Malaria was $6.8 billion in 2010 and was $6.5 billion in
2015.
However, he said that despite this, the
number of people on ART funded by PEPFAR alone had doubled during the same
period from 3.2 million to 7.7 million and that expanding treatment did not
have to depend on ever-expanding funding: “Putting the right people on the
right treatment in the right way in the right places” was what mattered, he
said.
The “right treatment” had to include
new ideas such as offering PrEP to high-risk HIV-negative people in the same
communities and pioneering “immediate test and treat” programmes that aim to
maximise retention by giving people their first ART the day they are tested.
The “right places” meant that resources had to be targeted at the countries not
just with the highest burden of need, but with the greatest unmet needs.
Shaffer and several other speakers
emphasised that choices would have to be made about what could be funded
efficiently. A study in Tanzania, for instance, Shaffer said, had shown that
many programmes funded under the budget line entitled 'Health Systems
Strengthening' were already funded from non-HIV sources to do the same work and
that it was not always necessary for HIV to carry the can for improvements in
healthcare infrastructure and process, especially in countries with expanding
economies.
Jonathan Mermin of the HIV, hepatitis
TB and STD prevention section of the US Centers for Disease Control and Prevention (CDC) agreed,
emphasising that the task of HIV prevention became ever larger as successes in
ART meant that the number of people with HIV in the world would continue to rise
for some time to come, from an estimated 29 million in 2000 to 37 million in
2014.
He criticised the adoption of an
undiscriminating “combination prevention” approach to HIV: the combinations had
to be of the measures that worked best in different populations and situations. “Not all prevention interventions are
effective and not all effective interventions are equal,” he said.
He said there was evidence that simply putting more people
forward for treatment was leading to global declines in HIV infections, quoting Andrew
Hill’s paper presented last year at the Melbourne International AIDS Conference,
which showed a strong correlation per country between the relationship between
the proportion of people on treatment and the relative increase in new
diagnoses. This shows, for instance, that in Botswana and Thailand, where 60%
and 55% of people with HIV are on ART, new diagnoses last year formed
respectively 4% and 2% of the HIV-positive population; in contrast in Nigeria
and Indonesia, where respectively 15% and 5% of HIV-positive people are on ART,
the increase in new diagnoses formed 8% and 12.5% of the positive population.