World AIDS Day: Big Questions on the Eve of HIV’s Pivotal Year

As we commemorate World AIDS Day on December 1, there are several big questions facing the HIV community as it looks ahead to 2020, which will be a pivotal year for the global HIV response. The answers to these questions could make or break the next phase of the global response. There is a need for a reality check as the world currently is not on track to reach the 2020 Fast Track milestones toward the goal of ending HIV as a public health threat in 2030, which come due at the end of the year. U.S. leadership is fragile. Political and financial will has stagnated for a decade, as has the number of annual new infections. Human rights conditions—key to service access—have worsened and complicated the HIV response in many countries. There are opportunities to capitalize on two decades of investment and innovation, but there are also significant risks that any backsliding will lead to regression.

The biggest question is whether the world will truly subscribe to the goal of ending HIV as a public health threat with enough financial resources to implement preventative and therapeutic approaches at the necessary scale. The platform to do so is the best it has been since the start of the HIV pandemic in the early 1980s, with more than 24.5 million people on antiretroviral treatment (ART) approximately 65 percent of all people living with HIV—as of mid-2019. Treatment regimens today are easier to use and less toxic, with more options to fit the individual needs of patients. The arsenal of prevention tools is growing more robust with oral pre-exposure prophylaxis (PrEP), a once-daily ART dose, providing a discreet, user-friendly method that has otherwise been missing for decades. Additional tools are on the way, such as long-acting regimens, injectables, implants, and multi-purpose technologies. There has been a 16 percent decline in new infections globally since 2010 and the potential for further reductions with wider use of these tools.

Concerted investment in aggressive policies, adoption of new science, and utilization of new tools has resulted in significant impact, particularly in Eastern and Southern Africa where the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund), among other donors, have focused their financial, programmatic, and technical advisory resources. There have been dramatic gains in life expectancy, uptake of treatment, and reductions in new infections. For example, in Eswatini, there has been a 20.4 percent reduction in new infections since 2015 and an increase in life expectancy of nearly 12 years. However, other countries are struggling, which is reflected in the global viral suppression rate of only 53 percent. As those with suppressed and undetectable HIV viral loads are unable to pass the virus on to others, high rates of viral suppression are a pathway to epidemic control.

Part of the challenge is money. Global resources for HIV have stagnated over the last decade with concerning declines since 2017, particularly by traditional donor countries. The U.S. government remains the leader through PEPFAR, the largest commitment to HIV by any nation in the world; contributions to the Global Fund; and a robust research and development portfolio. However, Congress has had to step in for the last three fiscal years to sustain flat-lined funding following significant proposed cuts in the president’s budget requests. PEPFAR funding peaked in FY 2010 at $5.57 billion, and annual appropriations have remained relatively flat since FY 2011; $6.8 billion (including $1.35 billion to the Global Fund) was appropriated for FY 2019. Continued flat-lined funding for PEPFAR has been seen as a win but has created pressure to streamline programs at the same time PEPFAR is trying to accelerate treatment initiation and support the Fast Track goals. As PEPFAR defines a new strategy in 2020 after its current Epidemic Control strategy ends, it is unclear whether the program will need to further scale back the number of countries it supports or decrease the scope of activities it is able to fund to account for the growing numbers of supported people on treatment (now 15.7 million in more than 50 countries).

One bright spot is that the Global Fund raised $14 billion at its Sixth Replenishment Conference in October 2019 to carry forward its operations through 2022, including $4.68 billion from the United States, which represents an almost 9 percent increase from the Fifth Replenishment Conference. However, even with sustained U.S. and Global Fund resources, there is simply not enough funding to support every country at scale. For example, South Africa, with the world’s largest HIV epidemic, has had to prioritize 27 districts in 8 provinces despite high levels of investment from the government, PEPFAR, and Global Fund.

Tough choices must be made about where to spend resources and why. Accelerating treatment uptake has been the central driving mission for most of the last two decades, with systems designed to initiate and manage care. That approach alone is not enough. According to the Joint UN Programme on HIV/AIDS (UNAIDS), 1.7 million people were newly infected with HIV in 2018—roughly 5,000 a day—and far from the 2020 Fast Track goal of fewer than 500,000 infections per year. Further, most new infections are occurring among 15 to 35-year-olds who are least likely to know their status, be on ART, or be virally suppressed. With the youth population growing at a swift pace in many areas of the world, the sheer number of people living with HIV could overwhelm health delivery systems. If prevention among that age group fails, the goal of bringing the global pandemic under control will remain elusive and potentially lead to disease resurgence.

Another question for 2020 is whether the global response can adapt to meet the shifting infection demographics. More than 50 percent of new infections in 2018 occurred among key population groups, such as men who have sex with men, transgender people, sex workers, and injection drug users, who face institutional and societal discrimination that create barriers to health service access. Many of the areas with growing rates of HIV among key population groups have repressive legal and societal restrictions, such as Russia and the Middle East and North Africa. Ensuring members of these groups, as well as adolescent girls and young women who are particularly vulnerable in sub-Saharan Africa, have access to available prevention and treatment tools will be essential to changing the infection dynamics. However, only approximately 340,000 people are on oral PrEP worldwide, far short of the 3 million target in the Fast Track goals. Greater use of oral PrEP could be transformative in high burden areas and for key population groups who risk harassment, arrest, or imprisonment. Addressing the barriers—political, financial, legal, health systems, stigma—that limit effective implementation of new prevention technology and provision of ART and other HIV services will be necessary to ensure impact, but it will not be easy. The U.S. government has ceded much of its leadership role on global human rights over the last few years, but working with governments to remove the barriers that stand in the way of effective HIV programs will be necessary to ensure PEPFAR’s success and protect $90 billion worth of cumulative U.S. investment.

The United States is not immune to these broader issues either, with approximately 1.1 million people ages 13 and older living with HIV. A decade ago, the number of U.S. infections was declining substantially each year, but since 2013, progress in preventing HIV has stalled. An estimated 39,000 people, most of whom are members of key population groups, have become newly infected every year since with an estimated 20 percent unaware of their status. The U.S. viral suppression rate is the lowest among comparable high‑income countries at only 52 percent. The plan to achieve epidemic control in the United States in the next 10 years, announced in the 2019 State of the Union address, comes with a request for the first significant new funding for HIV in nearly 30 years. However, the current continuing resolution expires the third week of December. There is considerable uncertainty about how the budget process will unfold and what that means for the plan’s year one $291 million budget request that was sent to Congress. It is further unclear what the impeachment process and November 2020 elections mean for global and domestic funding. Bipartisan congressional support has been challenged by attrition of former champions over recent election cycles but will be essential to sustaining U.S. HIV investment going forward.

The United States will also need to contend with changing dynamics in the global health community. Winnie Byanyima formally begins her tenure as UNAIDS executive director in January 2020. UNAIDS’s Fast Track goals were intended to catalyze accelerated effort in reducing new infections, initiating more people living with HIV onto treatment, and combatting stigma and discrimination within a short five-year window to put us on a track to end HIV as a global health threat by 2030. Strong leadership from UNAIDS is needed in 2020 to set forth a pragmatic and implementable vision for how to meet the 2030 target that unites the key players, such as PEPFAR and Global Fund. However, Ms. Byanyima’s focus on poverty alleviation and gender inequality may not align with U.S. priorities and could put her on a collision course with the United States. Her support for universal health coverage, demand for which is growing globally, may also challenge the relationship.

Universal health coverage and primary health care is a top priority for the World Health Organization director general as well. The debate about whether and how HIV efforts should integrate with other health areas is expected to intensify in 2020. Many country governments are eager to move away from siloed health streams, which may increase their conflict with the U.S. government as well. There may be confrontations if there is a push to reallocate PEPFAR money into primary health care and away from direct applications as outlined in the program’s authorizing legislation.

Fundamentally the goal of any and all efforts has to be ending HIV as a public health threat. Neither the Global Fund nor PEPFAR was established to end HIV. That was beyond the realm of possibility in 2002 and 2003, respectively. But we now have the treatment and prevention tools and the knowledge from nearly two decades of targeted investment to make it a reality. Current investments by PEPFAR and the Global Fund are not enough. The time is now for country and donor governments, including the United States, to commit fully to the goal of ending HIV in every country backed up by the political will and money to make it a reality. Two-thousand and twenty should be the year the world recommits to HIV and puts us on the path to success by 2030, not the year the momentum slips, and we lose the chance to end HIV.

Sara M. Allinder is executive director and senior fellow with 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).

© 2019 by the Center for Strategic and International Studies. All rights reserved.

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