World AIDS Day 2017: Time for the United States to Recommit to the Global HIV Fight

This year’s annual World AIDS Day commemoration on December 1 has a strange dichotomy. Despite some important reasons to celebrate what has been achieved and the potential for further progress, there are real concerns and tremendous uncertainty about the state of the global fight against HIV. Not only are there major hurdles to be overcome to prevent new infections and to treat and care for those already living with HIV, but there has been a trend toward reduced resources and high-level political will over the last six years. If we can overcome those obstacles, we could be on the path to controlling the pandemic. If we can’t stay on the path, we could be on a precipice where retrenchment leads to resurgence.

Thirty years on from the birth of the global HIV movement, there are good reasons to celebrate. On November 20, UNAIDS announced that nearly 21 million people living with HIV worldwide are on antiretroviral treatment (ART) as of June 2017, which is 2 million more than were reported to be on ART as of December 2016. For the first time in the history of the pandemic, more than half of people living with HIV were on ART in 2016. The remarkable increase in ART access over the last decade has led to a decline in deaths by more than 40 percent since 2010. Progress has been especially significant in eastern and southern Africa, the region with the highest burden, which has been the epicenter for the pandemic. Seven countries worldwide have achieved or exceeded UNAIDS’s 90-90-90 goals as of 2016, and 11 other countries are very close, including Lesotho, Malawi, Swaziland, Zambia, and Zimbabwe. Achieving these goals would enable countries to control their epidemics without a vaccine or cure.

Whether or not these achievements can be sustained is questionable, as we highlighted in our CSIS Global Health Policy Center HIV working group’s chapeau paper, “Opportunities for U.S. Leadership at Its Moment of Reckoning on Global HIV,” published in September. Despite ART gains, approximately 16 million people living with HIV still need ART, and there are notably poor rates of treatment access for children. Adult infection rates plateaued years ago and are stuck at approximately 1.8 million per year, which is an issue because the number of adolescents and young adults in Africa is expected to double in the next two decades. Twice as many adolescents and young adults could mean twice as many new infections, given that this age cohort is less likely to know its HIV status and be on ART. Newer epidemics, such as those in Eastern Europe and Central Asia, continue to grow unabated, driven by injecting drug use and low coverage of testing and treatment services. Globally, progress is being made toward getting patients on ART virally suppressed, which is important because those with undetectable levels of the HIV virus in their bodies are unable to pass it on. Rates are improving, but only 44 percent of people living with HIV had achieved viral suppression in 2016.

These gains have not come cheap, and accelerating toward pandemic control requires upfront resource investment. The world has invested more than $120 billion toward the global fight against HIV. It cannot afford to lose momentum or backtrack now. UNAIDS modeling indicates an opportunity to take charge of the pandemic in the next couple years with increased investment toward averting new infections and treating those already living with the disease. Unfortunately, that sense of urgency has not translated to the trend in resources, which has been downward over the last two years. In July, Kaiser Family Foundation and UNAIDS reported that donor government funding fell by 7 percent in 2016 to the lowest level since 2010.

The U.S. government has been the outright leader in global HIV since 2002. Of the $120 billion invested globally for HIV, more than $72 billion has come from the U.S. government alone. U.S. financing and programs have been instrumental in the achievements listed above and in changing the paradigm for how we understand what is possible in this fight. Presidential leadership has underpinned the success of the President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria. President Trump’s proposed $1.1 billion reduction in global HIV funding for fiscal year (FY) 2018 is an abrupt reversal of 15 years of U.S. leadership in advancing the fight. That reduction equates to an 18 percent reduction to PEPFAR, the U.S. contribution to the Global Fund, and critical HIV research and follows six years of flat funding since FY 2011. That PEPFAR has been able to continue to exponentially increase the number of people living with HIV on ART each year over this period is commendable. A contraction in resources calls into question its ability to do so in the future even with potential efficiencies gained through lower drug costs, differentiated service delivery models, and improved program implementation.

As I wrote in my commentary last World AIDS Day, Congress remains an essential partner to fighting global HIV, as demonstrated by both the House and Senate rejecting the president’s proposal and reinstating the FY 2017 Omnibus funding levels. That’s good because analysis indicates that the number of people on ART could decline by more than 830,000 and infections could increase up to 200,000 new cases if the cuts are implemented. Congress may have held off the cuts in FY 2018, but there is no reason to believe that the president’s FY 2019 budget proposal won’t include them again. Congress must continue to ensure critical funding is available for the long term. Even if epidemic control is achieved in a given country, there will still be a need to maintain both treatment and prevention activities. The United States has a moral obligation to ensure that the patients it has helped initiate on ART are able to stay on ART.

Congress can also play a greater watchdog role by pressing the administration on key policy questions (e.g., whether PEPFAR’s new strategy targeting epidemic control in 13 countries by 2020 results in continued treatment increases in those countries and what the impact is in the other 50 countries PEPFAR supports). Initial statements indicate that only patients currently on ART will be maintained in countries not covered in the strategy. At a time when we now know that putting people on ART and getting them virally suppressed is critical to stopping transmission of the virus, this new strategy is beyond concerning for the future of the epidemics in those 50 countries. The strategy seems driven by the proposed budget cuts, while also serving to justify the cuts. Congress also should be mindful of the impact of the reinstated and expanded Mexico City Policy on PEPFAR implementation and HIV prevention figures. It is not yet clear what this ideological position means for costs, implementation, and oversight.

Our HIV working group made six recommendations to the Trump administration and Congress: protect the unique U.S. approach to global HIV through investments in research, the whole-of-government PEPFAR bilateral approach, and multilateral contributions to the Global Fund; achieve HIV epidemic control in countries where it is possible in the near term while sustaining investments to prevent backsliding in others and investing in programs for adolescent girls/young women; incentivize partner country self-reliance to better share the burden of fighting HIV; and maintain HIV vaccine and cure research.

Of course, the United States cannot shoulder the burden alone. Other funder governments, local governments, corporate entities, and civil society must play greater roles through increased on-budget support, support to the Global Fund, and partnerships that leverage partners’ collective expertise. Country governments also must ensure that their domestic resources are allocated efficiently and effectively and that policies are in place to ensure those most in need of services are able to reach them, including populations that are subject to societal or state-sponsored discrimination. Working together, there is the possibility for great success. In a recent study, researchers found that if the United States increases its investment by 10 percent, along with increased domestic resources and optimized spending, there is potential to avert 22 million HIV infections and 2.3 million deaths over the 15-year analysis period.

As we mark this World AIDS Day and look ahead across the next year, the U.S. government cannot afford to retrench. The United States should recommit to its leadership role and the long game for winning against HIV, while increasing its diplomacy to boost political and financial commitments of partner governments. We must look beyond the immediate benchmarks and take the long view with efforts that move us along the path toward a time when HIV is no longer a public health threat.

Sara M. Allinder is a senior fellow and deputy director of the Global Health Policy Center at the Center for Strategic and International Studies in Washington, D.C.

Commentary is produced by the Center for Strategic and International Studies (CSIS), a private, tax-exempt institution focusing on international public policy issues. Its research is nonpartisan and nonproprietary. CSIS does not take specific policy positions. Accordingly, all views, positions, and conclusions expressed in this publication should be understood to be solely those of the author(s).

© 2017 by the Center for Strategic and International Studies. All rights reserved.

Sara M. Allinder
Senior Associate (Non-resident), Global Health Policy Center