Healthy Dialogues: December 2010
December 2, 2010
The Healthy Dialogues blog strives to create a dynamic space for conversations about current topics in health. We pick experts, from both inside and outside CSIS, to provide a range of views on a single topic. We hope that by stringing our experts’ responses together, an interesting and complex picture of the topic will be created. An integral component of this blog is you! If you have a topic you'd like us to address in the future, tell us. If you have a question you'd like us to answer next, ask it. We want to hear what's on your mind.
With December 1st marking World AIDS day and breakthrough prevention studies being reported this year, the Global Health Policy Center at CSIS decided to make HIV/AIDS the theme of December's blog. According to the latest report from UNAIDS, HIV infections have declined by almost 20 percent worldwide over the past decade. Additionally AIDS-related deaths are down compared to previous years and the number of people living with HIV is stabilizing. Two important studies released this year also offer hope. At the International AIDS Conference in July, the CAPRISA study that was unveiled showed a microbicide gel used by women before and after sex could reduce the rate of HIV infection by 40%. As recently as November, the iPrEx HIV Prevention Study reported that by taking a single daily pill containing two HIV drugs, HIV infection can be reduced by 44%, and by more than 70% if the subjects routinely take their medication.
Despite this positive news, HIV continues to be tragedy that kills 8,000 people every day. According to UNAIDS, over 33 million people live with HIV and there are 2.6 million new infections every year. While we should celebrate the recent progress that has been made, we also must be aware of the necessary work that remains to be accomplished.
This month the Global Health Policy Center is excited to have an impressive group of contributing writers answer questions about HIV/AIDS. December's writers include:
Katherine Bliss, Deputy Director and Senior Fellow, Global Health Policy Center and Senior Fellow, Americas Program
Heidi Larson, Director, aids2031 Project and Senior Lecturer at the London School for Hygiene and Tropical Medicine
Shannon Hader, Senior Vice President and Director of the Center for Health Systems and Solutions, Futures Group
Ron MacInnis, Deputy Director, Health Policy Project, Futures Group
J. Stephen Morrison, Director, Global Health Policy Center
Question: How do we implement a “country owned approach” when many countries with high HIV incidence have policies or laws that make it difficult to have an effective response?
There is no country that cannot have a country-owned approach. How effective the AIDS response is in any country, is another question. There are good and bad country-owned approached. Those that restrict access to servies such as harm reduction when there is significant HIV-transmission among injecting drug users, is a bad example of country ownership. Countries that monitor and understand where new HIV infections are emerging and do their best to support prevention, including with policies, is a good example of country ownership. In the new aids2031 book published by the FT press, AIDS: Taking a Long-Term View, the importance of country and local ownership AND the importance of more efficient, effective and locally relevant responses are among the top recommendations of the book.
Question: Women are disproportionally affected by HIV/AIDS, particularly in sub-Saharan Africa, what needs to happen to make progress more effective for women? How could the introduction of a female microbicide shape the course of the epidemic?
Question: December 1st is World AIDS Day, what lessons have we learned thus far about policies and programs that effectively combat the spread of HIV/AIDS?
A decade ago, while celebrating how much had been learned about “what works” for HIV between 1990 and 2000, I (and many others, many times, in many ways) called for a greater urgency in systematically applying what we knew to programs and services that directly improve people’s lives. [HIV infection in women in the United States: status at the Millennium,” JAMA. 2001 Mar 7;285(9):1186-92.] Over the last decade, we have made unprecedented gains in expanding critical HIV services, with millions of people better off than they were before with regards to HIV. But of course, we are far from finished. Lessons relevant to the next decade of our HIV response include:
1) Mapping is critical, and allows us to focus even more on “hot spots” of high prevalence or recent transmission:
Understanding the overall national picture of HIV for a country is necessary, but insufficient for an optimal response. Sub-national and local data can be useful in identifying geographic “hot spots”—areas of disproportionately high HIV prevalence or recent transmission. Then, local mapping that provides further analysis of the specific distribution of virus, behaviors, services, and people, can inform a strategic package of prevention services that “fits.” Innovative applications of geographic information systems (GIS) for prevention as we do for treatment, combined with analytic tools such as PLACE and triangulation with other epidemiologic and surveillance data, can provide meaningful mapping for prevention programs. We can’t expect that general information will lead to prevention packages specific enough to transform HIV transmission in a community.
2) New technology expands our overall prevention toolbox, and allows more—and hopefully more effective—combination HIV prevention strategies to be applied and evaluated:
This happens both through biomedical innovations, but also through general societal innovation that can transform our abilities to provide services. For example, recent biomedical interventions—male medical circumcision for HIV prevention, pre-exposure prophylaxis—add 60% efficacy or better, when combined with supportive and behavioral elements to drive demand or targeted utilization and adherence to high levels. In terms of non-medical innovation, the expansion of cell phones and the development of SMS technology are revolutionizing our ability to maintain connections among people over time and places at a frequency and scale that would be unmanageable through individual in-person outreach alone. As technology evolves, we must explore how to best incorporate the new possibilities in ways that potentially transform our response by re-defining the best combination of services for a given community, not simply adding a discrete and isolated new intervention.
3) The biggest challenge remains getting to scale:
The past decade of success has effectively destroyed the ‘futility’ argument—that somehow highly technical interventions (such as HIV treatment) simply can’t be done in certain settings. But getting to the necessary levels of coverage, effectiveness, and sustainability for HIV programs can’t just be “more of the same.” We need to dedicate ourselves to continued innovations in efficiency and effectiveness to maximize the yield of each investment. Our new investments must focus in on key elements that directly impact transmission, quality of life, and survival. We must also invest in program science on getting to scale—evaluating what works to transform communities as rigorously as we have evaluated what works to protect an individual.
Issues of getting to scale, approaching prevention as a rational combination of strategies targeted to the local situation, and improving the efficiencies and effectiveness of our programs are global issues. This means we’ve truly moved into an era in which multi-directional global exchange and learning will bring better solutions. My recent experiences working with Washington, DC to systematically scale-up HIV testing drew extensively on approaches that had already been applied in many lower resourced countries, that were far ahead in implementing provider-initiated voluntary HIV testing compared to the United States. Likewise, the NIH-funded HPTN 065 trial looking at the feasibility of testing, linkage to care, plus additional services in U.S. “hot spots” as a community-level HIV prevention strategy will hold important and useful lessons for other countries as well. This global learning perspective allows us to challenge our assumptions, push forward on innovation, and raise the bar for impact and sustainability. By 2020, how far will we have gotten towards the end of AIDS?
In the nearly three decades since AIDS was first reported, one of the biggest lessons we have learned is that AIDS prevention and treatment policies and programs need to be locally tailored to have the most impact. Global data averages - and even national averages - often mask local pockets of problems as well as successes.
The aids2031 initiative - an independent consortium launched by UNAIDS to take hard look at what we've learned in the first three decades of AIDS and to look at options for a better AIDS future - has a number of relevant findings and recommendations. The analysis and findings will be coming out in a new book, AIDS: Taking a Long Term View, to be published by the FT Press this month. Here are some of the highlights that are particularly relevant to the question of lessons learned on policies and programs:
- Programs and policies should adapt based on new and emerging knowledge to stay relevant.
- Researchers should prioritize the development of user-friendly tools to assess, characterize, and understand key drivers of national and subnational epidemics. Increased investments in ethnographic and other social science research are neede to guide and evaluate the development of AIDS programs.
- Greater investments are also needed to evaluate particular combinations of strategies.
- Focused research is needed to identify the factors that increase or decrease programmatic impact and efficiency - for example, by generating optimal unit costs for well-run programs.
- If the number of new HIV infections in 2031 is to be sharply lower than it is today, political leaders must build strong support for prevention programs and policies, even if they may show results years down the road. Policies and practices that stigmatize and marginalize groups or individuals at high risk of infection must be avoided.
- Focus prevention efforts on the populations and settings where they are most needed. Based on periodic assessments of the modes of transmission for new infections, decision-makers should select interventions and allocate resources to focus on the right mix of services in the right populations and geographic settings.
- Implement an all-out prevention effort in Southern Africa
- Ground prevention programs in the strengths of people living with HIV—Prevention programs should undertake massive training and hiring of people living with HIV.
- Intensified focus on treatment adherence - the focus should not just be on starting new people on treatment, but ensuring that people can stay on treatment.
- Mechanisms for local accountability that involve broad citizen participation should be supported, developed, and implemented.
- Concerted efforts should focus on improving the management of AIDS programs. Incentives should be developed to encourage efficiency, including strategic integration of AIDS interventions with other services.
These are just the highlights - visit the aids2031 website (www.aids2031.org ) next week to see a video of a panel discussion on the theme "AIDS:Taking a long term view" which discusses some of this points above.
As human beings regardless of our age, gender, socio-economic or ethnic background, we consider our health to be our most basic and essential asset. Being sick or unwell can keep us from education or employment, from attending to our family responsibilities or from participating fully in social activities. We are also willing to make many sacrifices to guarantee us and our families a longer and healthier life.
In the 1946 Constitution of the World Health Organization (WHO), the preamble defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. The preamble further states that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.”
As a student of public health I understood this to mean that the right to health is fundamental to realizing the rights to life and dignity for all people. And while I am thankful there are still legions of the world’s population who believe as I do, certain people’s rights are minimized by social and political bias in every country around the world. Because HIV demands public domain solutions that force us to address sex, sexuality, gender, poverty, drug use, diversity – all issues that most people see as “undignified”, “uncomfortable”, and not possible for political leaders to address without offending someone - we quickly learned that finding solutions to control HIV transmission would not be successful without changing course.
Since the mid-1980s biomedical research and innovation on HIV and AIDS has flourished. In 2010, life-saving medications are for the first time in history more and more available around the world, and clinical services are seeing a growing global marketplace not only for HIV, but for other previously neglected areas of health. To maintain expansion in research and global access, global health and human rights activists alongside the growing legions of people living with HIV and AIDS around the world, have had to fight and lobby each year to keep budgets and programs expanding.
And while the global response to HIV and AIDS has proven our collective ability to invent, improve and expand global access to life-saving medical treatment for a deadly virus – it has also, alongside the burgeoning phenomena of globalization in the past decades – illuminated and mobilized the complex and continuing global struggles for social equity and human equality. Worldwide, advocates have also had to invent ways to pressure human rights, government, UN, and social justice leaders to build awareness and evidence on social inequalities; to document where discriminatory laws and policies are hindering the HIV response; to build a case for the rights of people deemed less socially (and politically) valuable; and to keep us all reminded that biomedical solutions alone will not end HIV.
Today we can attest to, in every country of the world, links between the HIV and poverty, stigma and discrimination, including that based on gender and sexual orientation. We see the incidence and spread of HIV are disproportionately high among certain people, including women, children, those living in poverty, indigenous peoples, ethnic minorities, migrants, men having sex with men, male and female sex workers, refugees and internally displaced people. The discrimination these individuals suffer makes them (more) vulnerable to HIV infection, and least likely to have access to life saving prevention, care and treatment for HIV, and other health services.
I have learned it is impossible to extricate the HIV and AIDS response from larger issues of global health and social justice reform and from the articulation and protection of human rights. Political, social, legal, and rights-based programs and policies that protect individuals cannot be separated from public health and disease prevention. They go hand-in-hand. Seeking equity and equality for all to remain HIV-free, or to live healthily with HIV requires this belief that all human beings are equal, and all human beings have a right to health, just as you and I do.
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- A Conversation with Ambassador Eric Goosby